On the use of the ophthalmoscope in diseases of the nervous system and of the kidneys; also in certain other general disorders

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181

THE OPHTHALMOSCOPE

CLIFFORD ALLBUTT

' How may a man know whether he be so earnest is worth
enquiry ; and I think there is this one unerring mark of
it, viz. the not entertaining any proposition with greater
assurance than the proofs will warrant.'

LOCKE, Human Understanding.

L r C..FiLzerald aa MI pirn

CONGESTION PAPILLA

ON THE

USE OF THE OPHTHALMOSCOPE

IN DISEASES OF

THE NERVOUS SYSTEM

AND OF

THE KIDNEYS;

ALSO IN CERTAIN OTHEE GENERAL DISORDERS.

BY

THOMAS CLIFFORD ALLBUTT, M.A., M.D. CANTAB.

//I
FELLOW OF THE LINNEAN SOCIETY;

FELLOW OF THE SOCIETY OF ANTIQUARIES;

FELLOW OF THE ROYAL MEDICAL AND CHIRURGICAL SOCIETY ;

PHYSICIAN TO TFTE LEEDS GENERAL INFIRMARY,

AND LECTURER ON PRACTICE OF MEDICINE,

ETC. ETC.

f 0nbon anb feto Jlorit

MACMILLAX AND CO.
1871

[All riiifify >\;t/'n-i\l ]

OXFORD:

BY T. COMBE, M.A., B. B. GARDNER, AND E. PICKARD HALL,
PRINTERS TO THE UNIVERSITY.

TO

J. IUGHLINGS JACKSON, M.D., RE.C.P.

MY DEAR DR. JACKSON,

It was about the same time, I think, that
you in London and I in Leeds began to use
the Ophthalmoscope in the investigation of cere-
bral diseases ; and it was not among the least of
its many uses to me that it procured me the plea-
sure and the advantage of your friendship. Your
simplicity, truthfulness, and acuteness in the obser-
vation of disease, and your genuine insight into
facts so long obscured by the cumbrous and vain
phraseology of the Schools, have made your friend-
ship as valuable to me as a student of nature, as
the like qualities in your personal character have
won my warm regard as your friend.

I cannot but feel that this volume should have
come from your hand and not from mine. Circum-
stances, however, of many kinds, your encourage-

vi DEDICATION.

ment being among the chief of them, have deter-
mined me to publish my own experience in this
form : I have given my best pains and care to make
my little book of some worth ; to you, to whom I
dedicate it, to the illustrious Von Grafe, who has
passed away, and to all those whose work has en-
lightened this dark subject, must be given the first
fruits of my reward. Nisi enim alii ante nos impe-
dimenta removissent, via nobis libera et expedita
haud esset ; ita partem gloriolae cuj usque nostrse
haud exiguam debemus aliorum, qui ante nos eadem
tentaverant, laboribus.

Believe me, my dear Dr. Jackson,
Yours very faithfully,

T. CLIFFOED ALLBUTT.

38, PARK SQUAEE, LEEDS,
1871.

PREFACE.

SOME considerable parts of the present volume have already
been published. I may refer more especially to my paper
upon the < Optic Nerves and Retinas of the Insane,' which
appeared in the volume of * Transactions of the Medical
and Chirurgical Society' for 1868; to an article on 'Medi-
cal Ophthalmoscopy,' which appeared in the number of the
' British and Foreign Medico-Chirurgical Review ' for Jan-
uary, 1868 ; to some lectures on * Optic Neuritis,' which
appeared in the 'Medical Times and Gazette' between the
9th of May and the ist of August, 1868, inclusive ; and
to some papers on the use of the Ophthalmoscope in tuber-
cular meningitis and in spinal disease, which appeared in the
'Lancet' of May ist and May 8th, 1869, and of January
1 5th, 1870. Little or nothing, however, has been trans-
ferred to this book as it stood. I have found it necessary
to revise the whole, and to re-write large portions, in order
to add the results of more experience and to express maturer
opinions. Thus a great part, the far greater part indeed of
this volume, is now issued for the first time ; and its pages
might have been almost indefinitely multiplied had I thought
it right to use all my accumulated material, and to publish
a large number of cases. I have thought it better, how-
ever, to exercise much reserve in this matter, and to
publish my own conclusions, with a few illustrative cases

viii PREFACE.

only, rather than to print a mass of such evidence as may
be collected for himself by any practitioner who is inter-
ested in the subject.

It is with some reluctance that I have forborne to publish
a larger number of coloured drawings with the text. To
execute drawings of any value, however, is a very laborious
and a very costly task ; one which I would not have avoided
had it been a necessary one, but which is, I think, less neces-
sary now that so many useful plates have been published
by the leading writers on diseases of the eye, and now that
Liebreich has published an English edition of his invaluable
Atlas under the able management of Mr. Swanzy. More-
over, it seemed clearly undesirable to increase the cost of
a volume like this, which, as it contains an account of the
work of many and far better observers than myself, may,
I therefore hope, be within the reach of all medical men.

I desire to take the present occasion of expressing my
warm thanks to the many kind friends who have helped
me. To those, whether of my own profession or without
it and they, I am thankful to say, are many by whose
example I have endeavoured to teach myself to be indus-
trious and honest in my own labour, and to be generous in
my estimation of the labour of others, naming them silently,
I can offer to them no gratitude like the largeness of their
gifts. To others, from whom in addition to this I have
received especial assistance, I may have the pleasure of ac-
knowledging my debts. From Dr. J. W. Ogle, at St. George's
Hospital, I first received the idea of the probable value of
the Ophthalmoscope in cerebral disease ; from Dr. Hughlings
Jackson I have received constant encouragement, and that
liberal participation in the results of his works and thoughts
which those who know him best will best understand ; from
Dr. Lockhart Clarke, Dr. Dickenson, and Mr. G. H. Lewes,
I have received practical instruction in the microscopical
dealing with tissues, and much valuable help besides; and

.PREFACE. ix

Mr. Swanzy and Mr. Hutchinson have enabled me to enrich
my pages with the coloured drawings of the choked disk and
of neuritis in lead poisoning, which were executed for them
by Dr. Fitzgerald and Mr. Burgess. My colleague and
friend Mr. Teale, again, has placed me under obligations
which are as enduring as they are pleasant to be bound
withal, for he has given himself, his experience, and his
materials so generously and so continuously to me, that
I can no longer define between that which is my own
and that which really belongs to him. To Mr. Oglesby's
patient and intelligent industry I am much indebted for the
continuous observation and notes of many cases in which
I was interested. Dr. Crichton Browne, the Medical Su-
perintendent of the West Riding Asylum, has associated
himself so thoroughly with my work, and, by his aid in
many ways, especially in the supply and description of pa-
thological specimens, has so fully and so unselfishly contri-
buted to my undertakings, that I only fear, in giving him
the thanks which are due to him, to make it too clear how
disproportionate are his benefits to my accomplishments. At
the North Riding Asylum, Dr. Christie has in like manner
placed himself and his materials at my disposal on more than
one occasion.

To those in whose writings I have found help and in-
struction I have made particular references in the course of
my book.

38 PARK SQUARE, LEEDS,
1871.

CONTENTS.

CHAPTER PAGE

I. Introductory ........ 1

II. On the Examination of the Eye . . . .13

III. On the Aspect, Structure, and Connections of the

Normal Optic Nerve and Retina . . .22

IV. On the Variations from Health of the Optic Nerve

and Retina ....... 44

V. On the Relations between certain Intracranial Dis-

orders and Affections of the Optic Nerve and
Retina 74

VI. On the Ophthalmic Signs of Disease of the Spine . 196

VII. On the Retinitis of Albuminuria . . . .213

VIII. On the Retinitis of Leukaemia . . . .238

IX. On the Retinitis of Syphilis 250

X. On the Amaurosis of Diabetes . . . . -253

XI. On the Amaurosis of Oxaluria . . . .256

XII. On Toxic Amauroses . . . . . .257

XIII. On the Effect of Disorders of the Menstrual and

other Secretions upon the Optic Nerve and
Retina 281

Xll

CONTENTS.

CHAPTER

XIV. On Embolism of the Central Artery of the Retina
and its branches ....

APPENDIX :

Cases, 1123

Insanity with Epilepsy .

Mania .

Dementia ....

Melancholia and Monomania .

Idiocy ....

General Paralysis .

284

299
364
371
380
387
390
393

DESCRIPTION OF FRONTISPIECE.

THE coloured plate represents the state described (vide
page 54) as Ischsemia papillse, and called by Grafe the
Stauungs papilla. It was drawn by Dr. FitzGerald from
a case under Mr. Swanzy's care 1 . The patient was a
soldier who was admitted under Dr. Robinson for symp-
toms due to a sarcoma afterwards found in the centre of
the cerebrum. The patient was blind and the pupils di-
lated. Mr. Swanzy noted in both eyes great tumefaction
of the optic disk and tortuous and engorged retinal veins.
The tumefaction did not extend far into the surrounding
retina. After death the right eye was obtained for Mr.
Swanzy by Mr. Baker, and the following drawing of the
interior was made, showing the swelling of the disk.

There was no neuritis extending up the optic nerves
behind the eyes.

1 Vide 'Dublin Quarterly Journal of Medical Science,' February, 1871.

ON THE

USE OF THE OPHTHALMOSCOPE.

CHAPTER I.

INTRODUCTORY.

THOSE of us who find enough to fill their thoughts in time
as it goes, who seldom look behind them, and who are
consequently incapable of looking before them, such of my
readers, if any such there be, have little idea of the rapid
advance now being made in our knowledge of the nervous
system. It is not many years since a physician, now living,
a man of great acuteness, and one of the leading physicians
in London, said to me : ' They talk nonsense who pretend
to localize disease within the encephalon; ingenious guesses
you may make, but such guesses seldom prove to be worth
much in the dead-house.'

Probably there was a little of the whim of a vigorous mind
in this ; but can we imagine that even a whimsical man, if
he knew anything of the matter at all, could make such a
speech to-day ? Yet the speech was not absurd when it was
made. How unfair such a saying would now be we have
ample evidence in the writings of modern nervous patholo-
gists ; and no one, perhaps, would be more astonished than
the speaker himself were I to remind him of his long-
forgotten assertion.

The wonderful advance in our knowledge of the minute
anatomy and pathology of the central nervous system has
imbued a like spirit within clinical observers, and they,
leaving the vain traditions of their forefathers, and adjusting

B

n

2 INTRODUCTORY. [CHAP.

themselves less to preconceptions and more to things, are
winning their way onward into the most cherished secrets
of nature. Almost all this is due to the microscope to the
microscope and to that genuine temper of the observing mind
which begot and is begotten by the microscope. Professor
Rolleston, in his remarkable address on Physiology, read at
the British Medical Association at their Oxford meeting,
showed that the older anatomists were none the greater for
their freedom from distracting ' microscopische spielereien ; '
on the contrary, that they never reached the standard of
accuracy in visible things which the microscope has since
helped to establish. So it is in pathology: it would be
idle in me to bring forward examples to show that morbid
appearances without number, of a kind quite evident to the
naked eye, were never described with any adequate care until
the microscope raised the standard of care.

The minute precision of this and such instruments, so
far from encouraging a narrowly curious habit of mind, has
the very contrary effect. Not only was our knowledge of
the diseases of the nervous system of a very meagre sort
until the use of the microscope became general, but, I may
add, that our method was even unworthy of our knowledge.
Not only is the brain the most complex and least accessible
part of the body, and therefore the last to benefit by the
more vigorous and more philosophical mode of investiga-
tion, which may be said within the last few years to have
changed the face of the medical art, but it is in the de-
scriptions of the functions and of the disorders of the
brain, that what has been called the metaphysical or trans-
cendental habit of thought has most tenaciously held its
ground. Where the order of phenomena is most com-
plex and observation most difficult, there our theories most
readily escape the test of experiment. Unchecked by direct
reference to nature, theories which have a fair aspect, which
are clothed in imposing language, and which are sym-
metrical and definite, there continue to command assent,
although elsewhere discredited. No one would indeed now
dream of referring the functions of the liver or of the heart

i.] INTRODUCTORY. 3

to an immaterial principle residing in or about these organs,
yet many persons still cling to the opinion that the functions
of the brain are something more than the movements and
the relations of the cerebral tissues ; and they not unnaturally
therefore refer diseases of the encephalon to something more
than the abnormal movements of its component parts.

We are tempted, for instance, to give a reality to such
a disorder as epilepsy apart from the phenomena in which
we say that it is seen. We are led to forget that molecular
equilibrium may be disturbed to a greater or less degree in
the brain as in any other aggregate ; and instead of tracing
out deviations from health, we satisfy ourselves with naming
the morbid state as we see it in its fullest development, and
having named it we try to hope that it is explained. We
thus begin more or less consciously to use such a word as
' epilepsy' in the sense of a principle of causation, and to forget
that it is merely a name given to a more or less definite
group of irregular movements. Even in the writings of those
who take a clearer view of the value of such names as ' epi-
lepsy,' ' chorea,' and the like, we may often detect a tendency
to use such words too much in a pictorial sense. A brilliant
sketch of an epileptic state, for instance, is set before the reader,
and is presented to him as a * type ' or standard, by which he
is to regulate his conceptions of all similar states. Certain
marked features are held to be necessary to the proper consti-
tution of the 'type,' and all modes of irregularity of function
not presenting such features are held to be what they please,
but certainly not epilepsy. They must group themselves after
a given fashion, and present certain given characters on pain
of being neglected, or, at best, recorded as ' curiosities.' Yet
it is in these slighter deviations from the normal order, in
spasmodic neuralgias, local tremors, transient suspensions of
the senses, and such minor indications of lessened tension
and increasing instability, that we shall ultimately find the
explanation of the more ' typical ' forms of disorder. It is not
by setting up opposition standards to the standard of health
that we shall learn the modes of initiation of morbid changes,
but rather by watching the outskirts of health itself.

B 2

4 IN TROD UCTOR Y. [CHAP.

Before we can comprehend extensive changes, we must
familiarise ourselves with slighter ones, and so take with us
the clue to the larger mystery. We shall, no doubt, continue
to depict the extreme and complete manifestations of disorder
for clinical ends, yet if we are to discover their origin, we
shall have to desert this kind of synthesis for analysis. We
must unravel groups of phenomena, and trace each element
to its source. We must learn to have a less exclusive admi-
ration for brilliant displays of disease, and to cultivate rather
a perception of those many little various errors from healthy
order by which Nature chiefly seeks to betray herself. A straw
may show the way of the wind better than a falling tower.
A habit of thus wakefully regarding the minutest variations
of the normal state, and of verifying them accurately, is of
inestimable value, and is quite the opposite of that other habit
of setting up certain morbid standards or lay-figures to which
all changes are to be referred. It cannot be too earnestly
impressed upon our students that any new facts, however
small, if well observed, may lead up, and probably will lead
up, to some wider truth of scientific or even of immediately
practical importance. But to compare individual instances
of disease with conventional standards, is directly to discour-
age the observation of those lesser phenomena, and to teach
the student rather to pare them off as far as possible until he
can produce his case in trim with accepted models. The
baneful influence of this method of case-taking is but too
plain in all medical schools. Students are led to think that
facts which seem to them to be accessory are not only un-
worthy of verification, but are even intrusive, and rather spoil
the elegance of their case than otherwise.

I much doubt indeed whether such terms as ' epilepsy/ ' cho-
rea,' &c., will prove ultimately to be valuable as names. Their
signification will be found so indefinite as the study of tem-
porary and chronometric failures of function advances, that
I fully expect to see the groups which they profess to desig-
nate altogether broken up, and their elements grouped again
under higher and more philosophical names having reference
to other and wider affinities. We see 'this process in other

i.] INTRODUCTORY. 5

names, indeed, already going on. The name ' apoplexy/ for
example, is retained in our nomenclature rather from habit
than from any belief in its value ; and the term ' inflammation '
hangs on our lips by a very precarious tenure.

The way which is open to us for the discovery of the laws
of change in nervous organs must be, to a great extent, there-
fore, a way of destruction. Nothing is so conducive to a right
appreciation of the truth as a right appreciation of the error
by which it is surrounded. The successful investigator must
bring to test statements and conceptions which have been too
long accepted on faith, habit, or good-nature. He ftiust look
boldly behind certain large words which are now too often the
shelter of ignorance, and he must satisfy himself whether they
have any definite value or not. When it is seen how much
our current language really signifies, and when all techni-
calities, which took their rise in old and false methods, have
been swept out of sight, we shall feel, perhaps, a little bare,
but at any rate we shall have open field for our new researches.
When we have stripped off all overgrowth of heavy verbiage,
we shall see that there is no lack of facts, and in our endeavour
to verify those which we think we have, we shall continually
come across others which no ingenuity of our own could have
led us to seek for, but which may turn out to be of the greatest
practical value. Moreover, the steady pursuit of such a method
strengthens in the observer that spirit of open-eyed sincerity
which in the man of science answers to the catholic sympathy
of the greatest artists, and is the true magistery.

It is therefore with great anticipations not only of a direct
increase of knowledge, but also of a great purification of
method and of speech, that I now see the ophthalmoscope,
another arm of precision, brought to bear upon nervous dis-
eases ; an instrument requiring minute accuracy in the use,
and revealing modes of nervous change during life which
before could be known only after death and in their results.
I regard the application of the ophthalmoscope, not to the
diagnosis only, but also to the investigation of modes of
nervous change, as of very happy augury. It will, like the
microscope, not only teach us to see the new things which it

6 IN TROD UCTOR Y. [CHAP.

exhibits itself, but it will train our eyes to see many more
new thing's which before we had overlooked.

My readers well know the marvellous change which this
instrument has produced in the knowledge and method of the
oculist. Not only has it cleared up for him many doubts,
and has enabled him to recognise certain pathological states
which before were beyond his reach, but the new habits of
accuracy which it has encouraged are very evident also in
recent work in those departments of ophthalmic practice
where the ophthalmoscope is less needed. Recent inquiries,
for example, into the disorders of accommodation and refrac-
tion, and of the muscular action of the orbit, appear to me to
have been conducted in a genuinely scientific spirit, and have
led to results whose bearing upon more general laws of nervo-
muscular life may turn out to be most important 1 . What-
ever, then, may prove to be the practical value of the oph-
thalmoscope in detecting disease of the brain or spinal cord,
it has for me this great charm that its use must favour a
spirit of industrious and accurate observation, and must favour
also that wholesome disposition of mind which welcomes any
facts, however far away they may seem to be from traditional
doctrines or dignified theories. I can scarcely suppose that
the ophthalmoscope will, in the hands of the physician, ever
rank in usefulness with the stethoscope. I confidently be-
lieve, however, that as the invention of the stethoscope has
been of incalculable advantage to us, not directly only, by
revealing changes of tissue during life, which previously
could be but roughly guessed at, but also indirectly, by en-
couraging the study of diseases of the chest; so the ophthalmo-
scope will help us, not only by the facts it directly reveals,
but by stimulating work in the direction of nervous diseases.
Nor must it be forgotten that by means of the ophthalmo-
scope we are for the first time permitted to see the commence-
ment and progress of change in the life of nervous tissue, and
to ascertain the modes and times of such change.

This is not a slight matter ; and if to all these considerations

1 Cf. e.g. Grafe, ' Klinische Analyse der Motilitats-storungen d. Auges/
and the many treatises which have followed it.

i.] INTRODUCTORY. 7

I add, as I shall presently show, that the ophthalmoscope is
even already of much use in diagnosis, I shall have made it
clear that this instrument must be in the hands of every phy-
sician who wishes to speak with authority on the subject of
diseases of the nervous system. The great drawback to the
rapid introduction of new instruments is the labour required
in learning their use. Thus it is that many useful aids to
diagnosis the laryngoscope, the endoscope, the sphygmo-
graph have a kind of alacrity in sinking out of notice. Every
medical school is now, however, bound to teach its students
the use of the ophthalmoscope as carefully as the use of the
stethoscope is taught. But it is not easy for physicians who
have left the schools, and are engaged in practice, to take up
a new instrument which requires much skill in the using. I
can assure my readers, however, that a few hours spared for
this work are very well spent. The new glimpse thus gained
of a number of obscure and difficult diseases adds greatly to
the interest of study ; and I hope to show that the ophthalmic
signs of intracranial disease are so many and so important,
that the reader will probably agree with me that no records
of nervous diseases can henceforth be called complete
which do not contain an account of the ophthalmoscopic
appearances.

It has long been known that indications of changes in the
nervous system were to be found in the eye. Motor aberra-
tions, such as contraction or dilatation of one or both pupils,
squints, ataxy of the ocular muscles, and imperfect accommo-
dation ; disorders of vision, such as photophobia, diplopia,
hemiopia, and even amaurosis, have all been recognised as
occurring in connection with central disease. It was not
possible, however, until the discovery of the ophthalmoscope
by Helmholtz to attach any other than a very loose meaning
to the word ' amaurosis' 2 . Suspension of the visual functions
is often due to other causes than to disease of the optic nerve
or retina, and it is probable that some cases of so-called amau-
rosis are actually due rather to troubles of accommodation

2 Witness the often ill-quoted epigram of Walter, ' Amaurosis sei jener
Zustand, wo der Kranke nichts sieht, und auch der Arzt nichts.'

8 INTRODUCTORY. [CHAP.

than to any deficient power in the nerve of sight. A minute
study of the disorders of motility in and about the eye is quite
as important as a study of the variations of the optic nerve
itself. A slight droop of the upper eyelid, and an equally
slight deviation of the axis of the eye, will reveal the existence
of a meningitis to the physician who had previously hoped
that he was dealing only with a fever. I am unwillingly
obliged, however, now wholly to pass by other symptomatic
affections of the eye, in order to give exclusive attention to
the alterations of the optic nerve and retina, considered mainly
in their relation to cerebro-spinal disease.

It is but very recently that the profession has been made
aware that the interior of the eye presents any visible indi-
cations of the disorders of the nervous system, nor can we say
even yet that the great importance of these indications is
generally understood.

Another great drawback to the fiill appreciation of such
facts is the unlucky division of cases between the physician
and the ophthalmic surgeon. If the disturbance of sight be
that which most affects the patient, he goes the round of the
ophthalmic hospitals ; if, on the contrary, the disturbance of
the nervo-muscular functions be uppermost, he falls under the
care of physicians, who are naturally prone to overlook any
changes of the inner eye. As marked changes may occur at
the back of the eye with slight or with no disorder of the
visual function, it is not surprising that the physician should
overlook one half of the facts, and it as naturally happens, on
the other side, that the surgeon's attention is equally limited.
While the present absurd division of the profession into oper-
ators and non-operators continues, we must be content to urge
upon those physicians who take an interest in nervous diseases
to frequent the ophthalmic hospitals, where a wealth of mate-
rial awaits them, of which they have little conception. I am
able to assure my medical brethren that they will receive a
warm welcome from their surgical allies, who, in their turn,
are much interested in the relations of eye affections to more
general diseases. Indeed, physicians have little idea how
' medical ' are the ' Ophthalmic Hospital Reports ' and the

i.] IN TROD UCTOR Y. 9

' Ophthalmic Review / and to the medical work of ophthalmic
surgeons like Mr. Hulke, Mr. Hutchinson, and others in Eng-
land, and like Grafe, Sichel, Liebreich, or Desmarres abroad,
physicians are already deeply indebted. I wish I could say
that the physicians showed a greater sense of their obliga-
tions. The number of physicians who are working with the
ophthalmoscope in England may, I believe, be counted upon
the fingers of one hand. If I may judge from the publica-
tions of Galezowski and Bouchut, it would seem that the
same reproach cannot attach to our Continental neighbours,
who will, therefore, unless we bestir ourselves, make this large
field of observation more especially their own.

Dr. John Ogle was the first physician who called my atten-
tion to the probable results of ophthalmoscopic examination
in cases of cerebral disease ; and he published a paper on that
subject more than ten years ago in the ' Medical Times/ Dr.
Ogle then impressed upon our notice the very close relations
which exist between the cerebral and the intraocular circula-
tion, and he urged that the beautiful vascular structure of the
posterior parts of the eye might serve in its variations as an
index to the vascular condition of the intracranial organs.

That ' dim suffusions and cecities the most serene ' do often
visit the orbs of those suffering from cerebral disease is, as I
have said, no new discovery. I had made a list of references
and quotations from a long series of medical authors anterior
to Grafe who notice this connection, and I had intended to
publish the list here; it became, however, a very long one,
and, after all, that which we have to do at present is not so
much to establish the connection between cerebral and visual
disorders, as to establish, with the ophthalmoscope and the
microscope, the modes and times of these relations for pur-
poses of insight into the ways of nervous disease in general.
My object is not so much to prove the common concurrence
of the two sets of symptoms, as to discover the manner of it
and its calculable value in pathology and in diagnosis.

But it would be unfair to forget that something had been
done in interpreting the connection between amaurosis and
brain disease before the ophthalmoscope had been even thought

1 o INTROD UCTOR Y. [CHAP.

of. It had not only been pointed out that atrophy of the
optic nerves often followed scrofulous disease of the base of
the brain and other such cerebral affections, but also a few micro-
scopic investigations had been made by pathologists in such
cases 3 . In the prae-ophthalmoscopic period, however, amau-
rosis from cerebral causes was generally put down to a simple
paralysis of the optic nerve, with some wasting, perhaps, as a
remote consequence. Even those who are best familiar with the
ophthalmoscope will find it difficult to realise the fact that
fifteen years ago a descending neuritis was never dreamt of,
and was first revealed by the mirror to Sichel, Grafe, Lie-
breich, and the other earlier ophthalmic investigators.

The idea of an ophthalmoscope was suggested by Gum-
ming more than twenty years ago. Such an instrument
was invented afterwards by Helmholtz, to whom modern
science owes so much, and was described by him in his
c Beschreibung eines Augenspiegels/ published at Berlin in
1851. The invention created but little interest at the time,
and Mr. Spencer Wells 4 was among the first in England
to insist upon the great value of the ophthalmoscope in dis-
eases of the eye. It is difficult to say to whom we owe the
first important and careful observations of the modes of con-
secutive disease of the optic nerves. Sichel and Grafe were
perhaps the principal workers at first in this new field of obser-
vation, and the well-known essay of the latter, * Ueber Com-
plication von Sehnerven Entziindung mit Gehirnkrankheiten,'
in the ' Archiv. fur Ophth.' Band vn. Abtheilung ii. S. 58,
published in 1860, drew general attention to the great im-
portance of the subject. The study of these morbid changes
of the disk and vessels was thenceforth vigorously prosecuted
by Samisch, Liebreich, Schweigger, Hutchinson, Carter, and
many others.

Were I now about to treat of paralysis of the optic nerve
merely as a symptom, merely as one deviation from the normal
among the many which constitute the several combinations

3 Vide Jiingken, ' Lehre v. den Augenkrankheiten,' Berlin, 1832, and such
monographs as that of Davis on Hydrocephalus.
* ' Medical Times ' for September 10, 1853.

i.] INTRODUCTORY. 11

significant of certain and several cerebral lesions, then it might
be my duty to include in one survey, not the optic nerve alone,
but the other nerves of the orbit also. Or, if I conceived, again,
that the optic nerves were attacked on any transcendental
grounds on grounds, say, of the intimate association of the
visual function with the higher muscular co-ordinations then
it would be my duty carefully to compare the failures of the
special nerve of sight with the failures of the special nerve of
hearing, of taste, or of smell, and to include all the nerves of
the special senses in one survey. A strong distrust of trans-
cendent reasons, however, combined with, or rather consist-
ing in, a strong trust in anatomy, together with some fur-
ther confidence, justifiable or otherwise, in my own researches,
leads me to believe that the sufferings of the optic nerve are
due entirely to the peculiarities of its own structure and at-
tachments to its rich vascularity, its large share of connec-
tive tissue, and its extensive relations with the parts at the
base of the encephalon and not in any way to its special
attitude as a sense, not even in such disease as locomotor
ataxy. I must set aside, then, as foreign to my chief purpose,
all discussion of the very interesting affections of the orbital
muscles a discussion which is full of interest to the student
of palsies, but which I must leave for another occasion 5 . The
affections of the optic nerve and retina are so various and so
important, and shed so much light upon both pathology and
diagnosis, and they are concurrent also with so many lesions of
distant organs, that I shall bestow enough of my tediousness
on the reader in dealing with them alone.

I shall, in the first instance, describe the anatomy of the
optic nerve and retina so far as may be needful to give us a
true knowledge of the healthy standard, and in this descrip-
tion I shall assume a good deal as known that would other-
wise cumber the page. I shall, in the next place, endeavour
to trace the mode and time of variations from this standard,
beginning with the simplest and earliest. Having done that,
I shall be at liberty to take the various diseases in turn,

5 I hope hereafter to follow up this volume by another essay on the disturb-
ances of motion and nutrition in the eyeball.

12 INTRODUCTORY.

encephalic, spinal, renal, and others with which optic changes
are associated, and to describe, as nearly as I can, the way in
which such associations take place.

Before entering upon these chapters, however, I propose to
make a few remarks upon the manner of investigating the
states of the optic nerve and retina.

CHAPTER II.

ON THE EXAMINATION OF THE EYE.

I DO not purpose to give here such a description of the
methods of ophthalmic examination as we look for in com-
prehensive treatises on ophthalmology, but only to give
a few brief hints, addressed more especially to medical
observers.

First, as regards the choice of instruments. The portable
instruments, with a glass mirror and one convex lens, are
very defective. The mirrors should be made of metal, as
in the glass mirrors we have a double reflection at the
wide sight-hole, one from each of the two surfaces of the
glass; we avoid this in the metal mirrors by paring down
the metal very thin near the centre, and then piercing a
sight-hole which ought to be very small. Moreover, one
two-inch convex object-glass is insufficient ; a second of
about three and a half or four inches is quite necessary ;
and a concave lens is indispensable for the direct examina-
tion. The observer should therefore get a metal concave
mirror of about ten or twelve inches focus 1 , with a clip
behind it to hold ocular glasses; he should have, also, two

1 Many mirrors now sold have no focus at all. It is impossible with such
mirrors to regulate the circle of dispersion upon the retina with any accuracy.
Mr. Carter has recently shown that the mirrors in common use are too large.
He considers that a mirror ought not to exceed a shilling in size (vid. Lancet/
Dec. 24, 1870).

14 EXAMINATION [CHAP.

convex object-glasses, of two and four inches focus respec-
tively; and, finally, a concave lens for the direct examination.
If his own sight be defective, he must have in addition an
appropriate correcting ocular lens. Instead of having two
convex objectives, he may have one of two inches value, and
supplement it by a small magnifying ocular lens ; but it is
desirable to have two convex object-glasses, as in a short-
sighted eye a weak convex lens is needed, and a strong one in
presbyopia. My readers are perhaps aware that there are two
methods of examining the eye the direct and the indirect
method. The direct method gives a very large and distinct
view of minute parts, but the field of observation is therefore
small ; it is indispensable, however, in all careful investiga-
tions, and it is the only method by which we can form an
accurate estimate of variations in colour. The direct method,
as its name signifies, is the method of looking directly at the
retina itself. In the direct method we act precisely as we do
when we look at a picture through a common magnifying
lens, the crystalline lens of the eye being the magnifier, and
the retina the picture.

Every one knows that in looking in this way at a picture or
other object, the image seen is deceptive in this, that it ap-
pears to be not in the actual plane of the object itself, but in
another plane ; which fact is expressed scientifically by calling
the image seen not a real, but a virtual image. To carry out
this mode of examination, we have to approach our own eye,
armed with the mirror, very close to the patient's eye, and it
is desirable, therefore, to examine the patient's right eye with
our right eye, and his left eye with our left, to avoid rubbing
of noses, and also to leave the patient free to adjust his vision
for the distance or in the direction we require. The observer
must close the eye not in use. A close approach is necessary
in the direct method, partly on account of the small aperture
through which we have to look, and partly on account of the
action of the refracting media. Our eyes are primarily con-
structed to bring parallel rays to a focus upon our retina, and
we have in addition an accommodating power in the lens to
enable us to condense divergent rays also, so as to focus these

ii.] OF THE EYE. 15

upon our retina. But we have no dispersing- accommodation
to enable us to retard convergence of rays, and to delay their
uniting until they reach the retina. So, if we have to deal
with convergent rays, these will meet at a point anterior
to the retina, unless we can open them out by some artificial
means. In the direct examination we very often have to deal
with converging rays, or with rays that will be seen the better
for a little more dispersion, and for this end we interpose the
concave lens. We thus make the rays divergent, in which
state they are easily dealt with by our accommodation, and
focused upon our retina so as to form a picture or image.

In the indirect method, as its name likewise implies,
we no longer look directly at the retina, but we form an
image of the retina outside the eye, and look at that. As
this image is actually formed in the plane in which we see it,
it is no longer to be called a virtual image, as in the last case,
but a real one, and by looking at this real image of the retina
we indirectly see the retina itself. The image is made by the
interposition of a bi-convex lens in addition to the crystalline,
and is therefore inverted. The rays falling from the mirror
are condensed by the lens, and directed into the eye ; then the
rays which spring divergent from the reflecting surface of the
retina are recondensed by the crystalline lens, and emerge
as convergent pencils. These pencils are rendered still more
convergent by passing again through the artificial lens, so
that they are brought to a focus in front of it and between it
and the observer. If the lens be of two-inch focus, these rays
will be united, and will form a picture two inches in front of
the lens. At this picture, and not at the patient's eye, must
the observer look, and after a little practice the observer will
learn insensibly to accommodate his vision for this point. All
observers will do well to use a binocular or stereoscopic instru-
ment at some time in their lives. This instrument is not by
any means necessary for common use, but it is well to make
ourselves so familiar with the perspective view of the parts
of the inner eye, that we may readily interpret the appear-
ances of the flat picture. For example, any cupping at the
back of the eye can only be represented as a flat picture

16 EXAMINATION [CHAP.

by means of a monocular instrument, but if our memory is
familiar with the perspective view given us by means of a
binocular instrument, we more readily infer the dimensions
of the cup in depth. It is often very important, as we shall
see, to distinguish the cupping of amaurotic atrophy from
that of a commencing glaucoma. The binocular instrument
is used for the indirect method of examination, for the exami-
nation, that is, of the real inverted image.

Many practitioners shrink from the use of the ophthalmo-
scope, because they believe that a troublesome arrangement of
light and darkness is a necessary condition. This notion is
encouraged by the especial arrangement known to be in use
at Moorfields and elsewhere. Such management is less neces-
sary, however, than we commonly imagine. A well-darkened
room, and a bright and convenient lamp, are very important
at ophthalmic hospitals, because the observations taken there
are to be of standard value, and are, moreover, to be made as
easy as possible for students and unpractised gazers. But
after some practice, these arrangements are found to be less
needful than is commonly supposed. There are very few
houses in which I find it difficult to make an ophthalmo-
scopic examination. If the blinds are drawn down, a reflection
may be thrown into the eye from almost any gas pendant or
bracket ; or, in default of gas, a common candle may be made
to give light enough to show whether there be changes at
the back of the eye or not, and in the former case to show of
what kind the changes are. For minute investigations in our
consulting-rooms, a curtain or shutter and a good lamp should
be provided. For patients confined to bed, either a candle
may be used a wax candle if possible or perhaps a small
lantern containing a bulFs-eye lens, after a pattern once sug-
gested to me by Mr. Carter. I am rather disposed, however,
to dislike light from a distant concentrating lens, as it is
difficult to manage. M. Galezowski and other ophthalmolo-
gists use a kind of instrument which is adapted to daylight
examinations. It consists of two tubes, blackened within;
of these, the lower and wider is fitted with a pad to the orbit,
and the upper and narrower one travels within it, carrying

IL] OF THE EYE. 17

the lens at its lower, and the mirror at its upper end. It
is unnecessary, however, and I think inconvenient, to have
the mirror fixed. The tubes may be used quite well with
a detached mirror, held as usual in the right hand. But for
my own part I seldom now use Galezowski's instrument ; for
a little dexterity will enable any one to ascertain, even in day-
light, whether the disks and vessels are normal or not, and
within certain limits, indeed, to ascertain the kind of morbid
change, if any there be. Where, as in a hospital ward, the
room cannot be darkened, and the patient is in bed, and these
are the most unfavourable circumstances, I can generally suc-
ceed by placing a wax candle or a small paraffin lamp in the
proper position, and by shading the orbit at the side with the
hand which holds the lens, and in front with my body, to
obtain a useful view of the back of the eye. These rough
expedients often give us valuable knowledge which would
otherwise be entirely lost.

Dr. Beale has constructed an ophthalmoscope which, like
that of Hasner, carries the mirror, the lens, and the lamp in
one. I have a great dislike to fixed parts in any ophthal-
moscope, and the more the parts fixed the more troublesome I
find it to manipulate them so as to throw aside teasing reflec-
tions, to vary the positions of the lens, and to hunt over
the whole retina. Moreover, I like to change my lenses
at will, or to pass from the indirect to the direct examination,
all of which is impossible in fixed instruments. On the other
hand, I fail to see any advantage in fixing the lamp, even
when the lens must be fixed to a tube 2 .

The use of the separated mirror and lens for indirect
examinations cannot be taught by books, but may be taught
in five minutes by a demonstrator. The lamp is now placed

2 Since this was written I have made a use"ul daylight instrument in the
following way. Instead of fitting a padded tube to the orbit, I have a black
silk curtain which is attached all round the rim of the lens, and thence falls
round the orbital region of the patient. The lens is fixed to a short blackened
tube, within which the curtain is retracted when the instrument is not in use.
The mirror, unattached when in use, is screwed as a lid upon the tube when
not in use. With this instrument movement is easy in every direction. The
patient is examined in bed or upon a couch.

C

18 EXAMINATION [CHAP.

on the left of the patient only, and the operator takes the
mirror in his right hand, and the lens between the first
finger and the thumb of his left hand. He then rests the
second and third fingers of this hand on the patient's fore-
head, so as to steady the lens, and moves it to and fro
until he finds the focus. The fourth finger remains at
liberty, to raise the eyelid if necessary. In varying his
lenses, he will remember that, generally speaking, the size
of the field depends on the degree of the enlargement and
on the width of the pupil; the greater the enlargement
the smaller of course is the field, and the reverse. When,
as in the direct examination, we can approach the pupil,
we obtain, as I have said, a larger field. In the in-
direct examination it is best to arrange the condensing
lens so as to bring its focus upon the iris, the rays then
cross over and form a circle of dispersion upon the retina.
A plane mirror is easier for a direct examination than a
concave one, as it catches the light better; but this diffi-
culty is soon got over. The observer can only learn by
frequent practice how to escape teasing reflections, and how
to hunt over the retina; but, if he has no personal dis-
advantages to contend with, he will soon master all this.
At the commencement he will do best to examine an eye
under atropine, the use of which must afterwards be re-
stricted. A practical observer will generally try to do
without atropine. If atropine be used constantly, patients
soon become annoyed by the very unpleasant effect of par-
alysing the accommodation ; sometimes they will declare
that their sight has been permanently injured by it, espe-
cially if their amaurosis be progressive. Moreover, unless
very strong solutions be used, it is a certain waste of time
and trouble to treat the eye with atropine, and to wait
until the pupil be dilated. When, therefore, the observer
has become skilful enough to hold the mirror still, and to
throw the beam steadily upon the blind optic disk, while
the patient accommodates for a distant point, he will find
that by so doing he no longer keeps up contraction in
the pupil, and he is enabled to see well enough into the

ii.] OF THE EYE. 19

state of the optic nerve and chief vessels. In the great
majority of cases this is sufficient for the physician.

Should there be extensive change, however, in the retina,
rendering a large field of view necessary, as in retinitis,
or should it be intended to use the case for class demon-
strations, then it will be found needful to dilate the pupil
artificially. Such cases are the exceptions. Atropine will
also be needed for cases where the patient is unmanageable,
or when the pupil is closely contracted, as it often is in
such diseases as locomotor ataxy and general paralysis. On
no account should we drop atropine into the eyes of children ;
they never forget it, and all hopes of ever seeing their optic
disks is henceforth lost. If children are gently and cautiously
handled, the disks may be seen in the large majority of
instances. Let the mother hold the child in her arms in
a natural, easy position, with its back to the lamp, and
then let an assistant dangle a bunch of keys in the direction
in which the visual axis should be. The disk will come
quickly into view, and must be caught flying. I not in-
frequently find that babies are almost or altogether blind
from atrophy of the optic nerves, without the mother having
any suspicion of it, or she may perhaps describe the child
as late in ' taking notice/ We should therefore never omit
the attempt to examine, even if the child be fretful. It
has often happened to me to see a fretful child charmed
at once into silence when the beam has been thrown into
its eye. The wonderful bright thing may fascinate it, and
make it forget its woes for an instant; if so, let not the
golden moment slip away, for it does not return. Suckling
infants should be put to the breast ; while the mother gives
suck and caresses the child, the observations may in the
majority of cases be easily made.

I have stated in the journals on several occasions, that
it is of great importance to ascertain the boundaries of
the field of vision. The mirror, without this help, may at
times be insufficient to establish a diagnosis : for example,
the distinction between anemia and atrophy of the first
degree may be out of our reach if we look to the mirror

c 2

20 EXAMINATION [CHAP.

alone. The elegant and ingenious, and, as it would seem,
very effective instrument exhibited by Mr. Adams at the
meeting of the British Medical Association at Oxford in
1868, bids fair, in large institutions, to supersede other
means of mapping the field. I presume Mr. Adams has
slips of paper ruled to correspond with his glass hemisphere,
and that he tranfers his tracings to them for permanent
record 3 . I have been in the habit of using the old plan
as modified by Mr. Teale, which answers quite well enough.
He hangs a light black board against the wall from a pulley,
in such a manner that it may be raised or lowered so as
to bring the bull's-eye opposite to the patient's centre of
vision. The board is ruled, like a target, with concentric
circles. When the observation is to be made, a head-rest
in the form of a crutch, and measuring eight inches in length,
is placed with its pad against the patient's forehead, just
above the orbit, and its point is placed perpendicularly
upon the target. A white disk of paper at the end of a
rod is then moved about upon the field in such a way as
to test the range of the patient's vision in all directions,
while his eye is opposite and constantly directed to the
centre. As the disk is shifted from place to place, a plus
or cipher mark with a piece of chalk registers the result
upon the board. After the completion of this process, the
map of the field is readily transferred with accuracy to a
slip of paper ruled on a smaller scale to correspond with
the target; this slip is filed with the day's notes of the
case. The method gives trustworthy results, and it seems
perhaps all that need in a general way be desired. It will
hereafter appear how important it is that records of this
kind should be taken from time to time in cases of atrophy
of the optic nerves. It will thus be found that many
patients having distinct optic atrophy or neuritis and
who may appear at the same time to have good vision

3 Dr. Jeffries of Massachusetts has kindly forwarded to me the description
of his records of the visual field. It differs little from Mr. Teale's plan, the
most important difference being that the black board and the recording slips
are divided into squares of known proportions.

ii.] OF THE EYE. 21

have good central vision only, and have in reality lost a
large slice of the lateral portion of their visual field.

In cases of intracranial tumour indeed, when the tumour
is at the base, the state of the visual field is often of great
importance to us in pointing out whether the nerves be
attacked in their course. For if the tumour is seated upon
one nerve before the cihiasma the whole of the field will be
destroyed in one eye, whereas if it cuts one nerve or tract
behind the chiasma the right or the left halves of the field,
as the case may be, will be destroyed in both eyes.

CHAPTER III.

ON THE ASPECT, STRUCTURE, AND CONNECTIONS OF THE
NORMAL OPTIC NERYE AND RETINA.

THE present chapter need not be a long one ; but a short
one is necessary, not only on account of some details which
need description, but also because I desire to lay practical
stress upon the true method of investigating disease the
method, that is, of investigating minute and early deviations
from health rather than great examples of mischief. There
is no essential difference between Pathology and Physiology,
though we think and speak continually as if these two studies
dealt with distinct classes of phenomena. Pathology is but
the shady side of physiology ; their district, though seen
under different lights and in various aspects, is one and the
same ; nor can any one really know one aspect without
knowing the other also. Whether, then, disease be slow
or rapid departure from the paths of normal development,
this departure must still follow the certain laws of tissue
change, if not the particular processes of health ; as the
reader and I, if we stray from the Queen's highway do still
walk with legs, and do not, in becoming trespassers, cease
thereby to be anthropological. So tissues which yield to
temptation and, as Mr. Matthew Arnold would say, strive
no longer to realize their best selves, do not thereby cease
to concern the physiologist, but on the contrary, by the
very mode of their errors, do more fully demonstrate their
physiological capacities. The true view of life must com-
prehend not only the normal or most complex tissues, but

OPTIC NERVE AND RETINA. 23

also the multitudinous forms into which these may change
by loss of complexity : the false view regards physiology or
normal states of tissue as one thing, and pathology or
abnormal states of tissue as another. Sailors no doubt
regard storms and eclipses as highly pathological, and feel
aggrieved at the philosophical indifferentism of the astro-
nomer at home ; but they are wrong, and so are we when
we forget that no tissue can be called normal or abnormal
except in relation to particular parts, and that what is normal
in one place becomes abnormal if found in another. Our duty
then is, first of all to familiarize ourselves with the general
laws or modes of tissue growth as we see them throughout
the microcosm or the macrocosm, and secondly to learn the
special modes of tissue growth for each particular part.

Having done this we shall be in a position to call the
tissue we find in any place normal or abnormal, not on account
of certain features of its own taken apart, but on account of
its congruity or incongruity with the characters of a particular
creature, a particular organ, or a particular part. To deter-
mine what is abnormal then in the eye, we must first carefully
ascertain what are the peculiar modes and relations of tissue
growth in the constituent parts of the retina and optic nerve,
and their connections, and how far the variations of these
can be recognised directly or indirectly by means of the
mirror, or by the scalpel after death. Many parts of such
a description may of course be rapidly dealt with as they are
inessential or familiar to us all, and this the more as after
some hesitation I have determined to confine myself in this
treatise to a consideration of the parts connected with the
optic nerves only. The other parts of the eye, however, and
the muscles of the orbit present many changes of a most
interesting kind in themselves, and which have important
relations with disease elsewhere: thus the affections of the
mucous covering of the eye should be studied in connection
with the skin and other tegumentary surfaces, and the affec-
tions of the fibrous tissues with fibrous tissues elsewhere 1 ;

1 The cornea has recently been proved by Schweigger Seidel to have affinity
with the connective tissues.

24 OPTIC NERVE [CHAP.

while the study of the muscular aberrations in the orbit
present many most interesting problems and illustrations to
the student of palsies and of motor conditions generally.
To do all this well would need, I find, a book much larger
than I ought now to write ; in confining myself to the ner-
vous parts of vision, and describing and explaining their
changes, I shall have a task quite large enough for my
powers.

Beginning then from before, backwards, we find a delicate
coat, consisting in great part of nervous matter, which lines
the greater part of the cavity of the eyeball. This coat or
layer the retina is very transparent, so transparent in-
deed in fair people as to be invisible under ordinary cir-
cumstances ; it is nevertheless a structure of very high
complexity, and one which presents many interesting varia-
tions in different animals. It is incorrect to speak of the
retina merely as an expansion of the optic nerve, as is too
frequently done ; and it is incorrect not only in anatomy
but also in pathology, for the retina shows a good deal of
independence of the optic nerve in its liabilities to disease
as well as in its normal structure and its means of nutrition.

The accurate and valuable researches of Schultze into
the minute anatomy of the retina, prepared with osmic acid,
have added much to our knowledge of one of the most in-
teresting organs of the body 2 . It is very satisfactory to be
able to add that our countryman Mr. Hulke has not allowed
all the honour of these recent investigations to go to our
Continental brethren 3 . Among former observers we owe
most, perhaps, to Miiller, Bowman, and Kolliker. It would
of course be beyond my purpose to enter now upon any
description of the delicate tissues of the retina; I must

2 M. Schultze, * Zur Anatomie und Physiologic der Retina,' Bonn, 1866 ;
vid. et 'Arch, fur Mikroscop. Anat.,' Band in. S. 215, 372, 404.

3 J. W. Hulke, ' The Anatomy of the Retina in Amphibia and Reptiles,' in
Royal Soc. Archives, 1864. 'On the Anatomy of the Fovea Centralis of the
Human Retina,' Phil. Trans, vol. 157, Part i,p. 109. 'On the Retina of
Amphibia and Reptiles,' Journal of Anat. and Phys., Nov. 1866, p. 94. ' Notes
on- the Anatomy of the Retina of the Porpoise,' ibid. Nov. 1867, p. 19; and
' On the Bloodvessels of the Retina of the Hedgehog,' Phil. Trans. 1868.

in.] AND RETINA. 25

content myself with a short indication of its structure and
relations.

The tunica nervea is continuous with the optic nerve and
lies within the globe of the eye upon the vascular coat or
choroid. When looked for with the mirror in the healthy
eye, it is so transparent as almost to escape observation except
in very dark people, and the red choroid which shines through
receives only a slight gray tint from the overlying retina.
This is true, however, of the layers of the retina only ; its
vascular part, on the other hand, is beautifully distinct,
and has to be carefully watched by the physician, as we shall
see hereafter. An artery (arteria centralis retinae) enters the
retina, and two veins (venae centrales) leave it near the centre
of the optic disk, passing between the bundles of fibres in the
optic nerve, and so reaching the ophthalmic artery and the
ophthalmic vein respectively 4 . The artery generally bifur-
cates into a superior and an inferior branch after it has issued
from the disk, or at any rate after it has come so far forward
that the bifurcation is to be seen through the transparent
nerve bundles. Immediately afterwards it divides into four
or five main branches, which again distribute themselves to
the retina on all sides, subdividing until they become capillary,
and so return into the venules 5 . The venules gather them-
selves in the contrary directions, and assemble in the two
branches of the central vein ; these two branches, however,
do not meet on the hither side of the sclerotic, but dive
separately into the disk, generally at a small distance from
the artery. Within the optic nerve trunk they quickly unite
and form one trunk, which ends in the ophthalmic vein.
The central vein approaches, and for a while closely accom-
panies the artery, but is never enclosed in the same sheath
with it. One remarkable fact in the vascular distribution
of the retina must not be overlooked, and that is the deviation

* It would be a waste of time and space to describe minutely the distribution
of the vessels, as they vary extremely in numbers and direction in different
people. The point of their entrance and exit is also various : in a person I
once saw the point was outside the rim of the disk.

5 In many animals there is a curious sinus around the ora serrata called
the circulus venosus.

26 OPTIC NERVE [CHAP.

of the vessels from the region of the yellow spot. This, in
my experience, is invariable. The branches on the external
side which turn towards this spot, bend and form arches
round it : no vessels of more than capillary size approach it,
so that it is thus left unimpeded for clearest vision. The
observer must bear in mind that the fovea centralis to the
ophthalmoscope appears indeed to be extra vascular. It is not
generally difficult to distinguish between the larger arterial
and venous branches in healthy retinas. The arterial branches
are smaller, straighter, and of a paler or rose colour, while
their transparency gives them the appearance of a double out-
line 6 . The arterial branches, again, are more superficial than
the venous, and may often be seen to cross them ; indeed, at
times when the veins are full, the overlying arteries may
appear even to strangulate them. In retinal hypersemia, how-
ever, the distinction between arterial and venous branches is
soon lost. These remarks must be understood to apply to the
main branches only, but the smaller branches can easily be
traced up to these. Besides the central vessels and their
branches there is also a variable number of small arterial
and venous twigs to be seen on the papilla. These branch
and anatomose variously with the vessels of the retina and
choroid, and thus form a vascular connection between the
ciliary and retinal blood-vessels. (Leber, quoted by Stellwag.)
These small vessels are much increased in number and in size
during states of hyperaBmia. The retinal coat may be traced
with ease after death, as its transparency becomes clouded and
a white filmy tunic is then to be seen extending from the disk
to one-eighth of an inch behind the cornea, becoming thinner
as it advances, and ending in a finely serrated edge called the
ora serrata. The thinnest portion of the retina, however, is at
the before-mentioned spot of Soemmerring, which spot is
almost, though not exactly, in the axis of the eye. The optic
disk the blind spot is slightly to the inside of the yellow
spot, and is insusceptible of light. The constituent tissues
of the retina are, as I have said, very complex, and need not

6 This appearance is now said to be wholly or partly due to the different
refractions of the arteries and veins.

m.] AND RETINA. 27

here be described. To two of its constituent tissues, however,
I think it is desirable to refer to the connective tissue frame-
work and to the nervous layer. Without discussing the
genetic relationship of the more specialized layers of the
retina to connective tissue, I may say that we* have known,
since the publication of H. Miiller's researches, that there is
a distinct framework of this bind web consisting of stouter
radial and more delicate trabecular parts which comprise
and support the more highly specialized structures. This
fact is of great moment in estimating the probable character
of inflammatory changes in the retina, and in explaining the
occurrence in it of gliomatous and other tumours. The in-
ternal or nervous layer of the retina consists of two parts : the
first or outer is a stratum of nerve cells and granules, and the
second or inner is a stratum formed from the fibres of the
optic nerve, which on leaving the optic disk lose their sheath,
so that their central part or axis only is carried forwards.
These axial fibres soon run into a continuous film, forming at
first a delicate web with narrow elongated meshes. There is
no fibrillar nervous matter, however, at the yellow spot.

With the convergence of the vessels we reach the papilla, or
optic disk, a little part of great importance in our present
inquiry, and which I shall therefore describe somewhat more
at large. This disk, the entrance of the optic nerve, is the
most striking object at the back of the eye. It is a small
round or oval spot, of a delicate rosy or creamy white tint,
contrasting with the pinkness of the surrounding choroid
and with the retinal arteries and veins which traverse in
order to dip into the optic nerve bundle near the centre of
it. The margins of the disk in the healthy eye are even and
sufficiently well defined; though in disease, as we shall see
hereafter, its contour may become much sharper or much
dimmer. The form of the disk is generally an oval with
the longer diameter vertical ; the vertical diameter, however,
exceeds the transverse by a very small difference, and in
many eyes the disk is round. I have in a few cases seen
the disk transversely oval; in one of these the variation
was only apparent, and was due to the defect of the cornea

28 OPTIC NERVE [CHAP.

known as astigmatism ; in other cases it seemed to be an
unimportant peculiarity, though I have twice seen it in cases
of atrophy. The size of the disk is actually about 0.75 lines
in its transverse diameter, and about 0.7 lines in its vertical,
according to the measurements of Jager 7 and H. Miiller 8
taken in full-sized eyes ; in many persons it is probably
less than this. The apparent size, and also the colours of
the disk, vary with the method of observation, whether
direct or indirect, and again of course with the power of
the lenses used in examination : with an ordinary two and
a quarter inch convex lens the inverted image appears to
be about the size of a small split pea, and with a four inch
convex lens of about the size of a groat. When magnified
to this size, as it ought to be in all important cases, or when
examined by the direct method, its texture becomes more and
more definite, its edges shade off more into the fundus, and
the degrees of its vascularity are far more easy to determine.
Finally, the apparent size of the papilla is changed by the
conditions of the refracting parts of the eye.

The margin of the disk is sometimes surrounded by a
crescent or ring, which may be white or black. The white
ring may mislead an unwary observer into the supposition
of a cupped disk, a staphyloma, or an atrophy. The variation
I mean is however congenital, and is explained in two ways :
one explanation is that the choroidal ring through which the
optic nerve trunk passes into the interior of the eye may be
a little larger in diameter than the trunk, in which case more
or less of the brilliant bluish white sclerotic coat would be
exposed to view through the transparent nerve fibres, and
would appear as a segmental or circular collar around the
disk ; the other explanation is, that the fibres of the internal
neurilemma of the optic nerve are not arrested at its entrance
into the globe, but are prolonged up to the papilla, in which
case there would be a white ring or crescent round the latter,

'Ergebnisse der Untersuchung der Menschlichen Auges mit dem Augen-
spiegel.' Wien, 185;, pp. 8-10.

8 ' Anat. Phys. Untersuchungen ttber die Retina.' Leipzig, 1856, pp. 80-82 ;
vid. et Grafe's Archiv. N. 2, Miiller and Liebreich.

in.] AND RETINA. 29

not interfering with vision. I am disposed to think this
second explanation the more probable, as a faint white ring
round the disk may always be detected in the erect image,
and indeed in some abnormal eyes the neurilemma is on the
contrary lost too soon, and there is a want of substance about
the disk which may simulate excavation. I have seen one or
two such cases. A very little practice will make it easy to
the observer to recognise an excess of neurilemma. He will
see that there is no glaucomatous excavation, that the white-
ness does not encroach upon the disk, and that the vessels do
not dip under it as they would dip under the edge of a cup.
If the circle or, as is more common, the crescent be black, it is
due to a deposit of pigment in the choroid around the disk,
and is of no ill meaning. I believe that it is sometimes
stated to be peculiar to people of advanced years, but I have
certainly seen it occur, and have sketched it as existing, in the
eye of children. It is never uniform, but presents patches and
gaps at various points in its course. The pigment lies of
course under the retina, and is really choroidal ; the pigment
of the choroid being always denser in the neighbourhood of
the disk. The disk itself is not exactly a transverse section
of the optic trunk, but is rather the centre of dispersion, from
which its fibres sweep in a cup-like expansion to form part
of the retina, and the vessels which enter the eye at the disk
sweep from it in the same way. Nor is it a raised spot, as the
name ' papilla' would seem to signify, or indeed does signify ;
on the contrary, the healthy disk presents a trifling de-
pression (porus opticus) about its centre, or rather at that
point close to its centre where the retinal vessels issue.
This part is extravascular and therefore whiter than the
rest of the disk, and it consists of the connective tissue
which invests the central blood-vessels. In slight cases of
congestion this white centre, which generally appears to be
of about the size of a small pin's head, shines out in contrast
to the rest of the disk. In fuller states of congestion, how-
ever, this centre itself becomes flushed like the rest of the
part, and I think it quite unnecessary, if not misleading or
erroneous, to give a distinct name, ' peripapillary congestion/

30 OPTIC NERVE [CHAP.

to the former appearance, as one recent writer at least has
done.

I have said that the optic disk is of a rosy, or creamy white
tint, and I shall now proceed to explain how this rosy tint,
which varies according to the mode of examination, which
differs a little in shade in various persons, and is often a
little deeper towards the (real) inner half of the disk, is due
to a special vascular system enjoyed by the disk in inde-
pendence of that of the retina. If I am not mistaken, the
disk and retina were supposed to draw their blood-supply
from a common source, until Galezowski pointed out that
the vascularity of the disk was independent of that of the
retina, and rather formed a part of the vascular system of
the brain. Since I became acquainted with Galezowski's
views in 1866 I have gone carefully into this important
question, and I have satisfied myself by means of many
dissections, microscopic and other, of injected parts, and also
by observation of the behaviour of the disk and retina in
disease, that Galezowski in this important matter is mainly
right. I say this important matter, for Galezowski's view,
if well founded, is of great weight if it tends to establish
still more a physiological division between the disk and
retina, to explain more clearly their remarkable indepen-
dence in disease, and above all to prove that the vascularity
of the disk is a cerebral vascularity closely connected with
that of the encephalon, and therefore a better guide to the
state of the encephalon than the retinal circulation can be.
The retinal veins and arteries, though scarcely brought into
nutritive relations with the optic trunk, are nevertheless of
course closely associated with it, for we found in tracing
the course of the retinal veins and arteries that they pene-
trate the disk about its centre, and actually enter the optic
nerve-trunk. The nervules and the vessels then pass through
the sclerotic together, the vessels lying in the middle of
the bundle, and so they pass on into the orbit, the artery
indeed passing through the optic foramen, but the vein
escaping a little sooner from the bundle and passing by
the ophthalmic vein and sphenoidal fissure into the cavernous

in.] AND RETINA. 31

sinus. Such a geographical relation between the optic ner-
vules and the vessels is very curious, and unparalleled any-
where else in the body. This peculiarity, and the further
peculiarity of the structure of the optic trunk, leads me to
look upon it not so much as a nerve proper, but as a com-
missure or bundle of nervules. I look upon it, with its
rich connective tissue and its rich and special blood-supply,
as a more important offshoot of the encephalon than any
ordinary nerve would be, and as likely therefore to offer
more important indications of its varying states.

The optic nerves take their rise chiefly from the corpora
quadrigemina, which bodies, and the anterior pair in parti-
cular, on grounds both of physiology and of pathology, we
now regard as the principal, if not the only true centres
of vision. Two little tracts or ribbons take their rise in
the corpora quadrigemina and optic thalami, from a dis-
tinct nucleus, in which latter they receive a few fibres, cross
the inferior surface of the crura cerebri, taking fibres from
the geniculate bodies, and then detach themselves almost
completely from the encephalic mass. After this detach-
ment they become more cylindrical, they lie at the base
of the brain, and the two tracts unite to form an
elaborate commissure called the chiasma, from which again
the * optic nerves ' branch off to each optic foramen. The
remarkable decussations in the chiasma establish a direct
commissure between the two eyes in front, and a crossed
commissure between each eye and the visual centre of the
opposite side, the remaining fibres being left to form a
direct connection between each eye and the visual centre
of its own side 9 . The chiasma is an oblong nervous mass
of some size, seated in front of the sella turcica and the
pituitary body. Its hinder horns run under the floor of the
third ventricle. Behind it is the pineal gland. It will be
seen at once that the nerves run along under that very part
of the base of the brain where lymph is mainly generated
in affections of the membranes of the base. The chiasma

9 I give the accepted view of the chiasma, which, however, is now called in
question as regards the arrangement of some of its fibres.

32

OPTIC NERVE

[CHAP.

has also very close relations with important blood-vessels.
The coronary sinus, or a part .of it, is situated close behind
and below this body ; the cavernous sinuses are in its imme-
diate neighbourhood, and large cerebral arteries lie beside
and in front of it. Now, according to M. Galezowski, the
optic tracts and nerves receive several very important blood-
vessels in their course. In the chief place, the optic tracts
receive a very extensive investment from the pia mater,
which covers and adheres to all its free surface; anteriorly,
where the tractus is approaching the chiasma, nearly two-
thirds of its circumference are clothed by pia mater, and
farther back that membrane even insinuates itself a short
distance between the posterior or inner margin of the tractus
and the adjacent surface of the crus cerebri. The more
special vessels of the central nervous organs of vision are
described as follows by Galezowski, whose words are almost
literally translated :

* i. An arterial branch entering at the posterior border
of the testes, and distributing itself to them. This Gale-
zowski calls the artery of the testes, or the posterior optic
artery.

* 2. Four vessels of some size which pass into the optic
tracts on the level of the posterior border of the cerebral
peduncles, and so by a well-marked line divide the optic
tracts from the corpora geniculata. Two of these vessels
are arteries, and they may be called the vasa geniculata
or middle optic arteries. They arise from the choroid
plexus.

* 3. A rather large branch coming from the middle cerebral
artery, and which passes to the corresponding optic tract.
This may be called the anterior optic artery.

'4. Finally, filiform branches passing from the pia mater
to the chiasma/

The veins are associated with the arteries, and need no
special description 10 .

10 In addition to the vessels described by Galezowski, and which account
for the well-known independence of retinal hypersemia and discal hyperaemia,
there is, on the other hand, at the nerve entrance a very curious connection

in.] AND RETINA. 33

If in addition to these vessels we also bear in mind, as
I have said; that the optic nerves and tracts are very exten-
sively and closely invested by the pia mater, which gives
off nutritive branches to them, we shall have a clear idea
of the mode of this circulation which nourishes the optic
tracts and nerves. Nor, when we look at the size and
complexity of these parts, shall we feel any surprise at so
elaborate a vascular supply. Now all these branches unite
to form an uninterrupted network of vessels which extends
from the tracts to the disk, and it is to them that the rosy
tint of the disk is due. Its vascularity is mainly therefore a
cerebral vascularity, and not an offset of the ophthalmic artery
like the vascularity of the retina. I hope to show that these
apparently small details bear closely upon the phenomena
of morbid change as seen by the ophthalmoscope.

In accepting the description I have quoted above, I ought
perhaps to add that it does not exactly coincide with nine
dissections of the injected parts which I have myself made
for the special purposes of this investigation. On the other
hand, however, my own preparations did not quite agree
among themselves, and in two cases I found a slight differ-
ence in the arterial distribution between one side of the
brain and the other. At the same time it is not important
now to discuss the matter as a mere question of minute
anatomy, and if Galezowski's observations are taken in his
own words, the reader will fall into no great error 11 . Any

between the vessels of the nerve, of the retina, of the chorio-capillaris, and of
the ciliary systems. It is not difficult to demonstrate by careful injections the
existence of an arterial circlet without veins which surrounds the nerve in
the sclerotic foramen. This circlet is formed by arterioles from the short pos-
terior ciliaries ; from it, again, minute twigs enter the nerve, and ramify in the
canals of the neurilemma, where they anastomose with fine twigs from the cen-
tral vessels. Fine branchlets also pass directly into the disk from the choriod,
so that we get a kind of threefold continuity between the disks, the retina, and
the chorio-capillaris, by means of an exquisite intraneural and perineural net-
work. These vessels are not, however, of great nutritive value, or of much
practical importance in this place ; for further details, therefore, I refer the
reader to the admirable researches into the vascular svstem of the human eye
by Leber, 'Arch. f. Ophthalm.' xi. I, pp. 4-7 (1865).

11 In a subsequent essay ('Arch. Gen. de laMed.' Dec. 1868) M. Galezowski
accepts my views, published ('Med. Times/ May 9, 1868) almost in my pre-

D

34 OPTIC NERVE [CHAP.

variations which may hereafter be found to occur in the
exact mode of the distribution in various brains, will not
in any way affect the main question of a rich independent
capillary circulation in the optic tracts and nerves extend-
ing up to the disks, and belonging to the cerebral system
of vessels. In the optic disk, then, we have an expansion
of the nerve fibres of the optic trunk, we have a capillary
circulation continuous with that of the brain, we have the
trunks of the larger and more independent retinal vessels,
and we have a certain considerable quantity of connective
tissue, part of which appears at the central depression and
sheathes the retinal vessels ; the remainder extends from the
peripheral neurilemma inwards, and makes a framework for
the optic bundle which I shall presently describe. As it
passes backward from the disk to the orbit, the nervo-
vascular trunk passes through a foramen in the sclerotic
coat, which is at this point of entrance denser than at any
other part of the eye. The opening seems to be guarded
by a pierced plate, called the cribriform plate ; this is really,
however, an arrangement of the neurilemma, which here
becomes continuous with the border of the opening, and
exposes the open ends of the longitudinal canals. These
sieve-like openings are to be seen through the transparent
nervules in many healthy eyes, and in some cases of atrophy
they become very evident. The margin of the foramen in
the sclerotic forms an unyielding ring, called the sclerotic
ring, and the nerve trunk as it traverses the sclerotic shows
a slight constriction. It will be seen hereafter that the
relation of this sclerotic ring to the optic trunk, with its
nervules and vessels, is of great practical importance. As
it leaves the eyeball and traverses the orbit, we find that
the optic trunk is invested by a tough outer sheath, which
is easily detached, and which seems to be continuous with
the sclerotic on one hand, and with the dura mater on the

sent words two years ago, as corroborative in the main of his own. He states
that M. Sappey has 'pleinement confirm^' his conclusions by his own re-
searches, and quotes them in his lectures. Also that M. Fort embodies them
m the last edition of his 'Anatomic Descriptive et Dissection/ t. iii. (1868).

in.] AND RETINA. 35

other. Whatever may be their genetic relationship, how-
ever, it has been shown by Sappey 12 that this sheath, though
continuous with these structures, differs much from either
of them. He shows that the optic sheath is rich in elastic
tissue, which is not found in the dura mater or in the sclerotic,
and that the nervi nervorum are peculiarly abundant in it.
On removing the outer sheath of the optic bundle, we find
below it a second sheath, also enclosing the bundle, but
not to be stripped off from it. This inner sheath, which
is continuous with the pia mater, is thinner and less com-
pact in structure than the outer sheath, though more dense
and fibrous than the pia mater.

The two sheaths, therefore, enclose a cavity which may
be said to be continuous with the intermeningitic cavity
of the brain, and which may perhaps become distended by
the transference of any fluid effused at the base of the
brain. This is confidently stated to be the case : I have
had no opportunity of verifying the statement, and con-
fess to some scepticism about it 13 . The visceral arachnoid,
indeed, after accompanying the nerve fairly into the hole in
the sphenoid bone, becomes reflected on the process of dura
mater lining that aperture; so that the space between the
sheaths cannot at any rate be continuous with the arach-
noid cavity. The inner sheath not only encloses the optic
bundle, but forms a part of it : it sends off processes or
partitions which pass into its substance and divide it into

12 Robin's 'Journal d' Anatomic,' Jan. 1868. Vid. et Ponders; Grafe's
'Archiv.' I. 2, p. 83.

13 This statement, which I doubted upon grounds of clinical experience,
is now, however, proved by the accurate researches of Schwalbe (Schultze's
'Archiv.' vol. vi. Part I, 1870). He has investigated the eye by means of
silver solutions, after Recklinghausen's method, and has demonstrated the
existence of two lymphatic cavities, the one ' supra- vaginal,' and extending
around the choroid, between it and the sclerotic; the other 'sub-vaginal/
occupying the space mentioned in the text, between the two sheaths of the
optic nerve. It has, like the supra-vaginal cavity, the lining and other
characters of a lymphatic cavity. Schwalbe shows that it is no doubt continu-
ous with the similar interarachnoid lymphatic cavity, but towards the disk is
closed, so that although it can be injected from the arachnoid cavity, yet the
injection cannot enter the eye. Clinically, therefore, I was right, anatomically
I was wrong.

D 2

36 OP TIC NEEVE [CHAP.

numerous longitudinal channels, along which the filaments
are carried. These partitions, then, are continuous with,
or form the sheaths of, the fibrils themselves, a peculiar
arrangement which shows again that the optic nerve is
not strictly a nerve, but rather a bundle of nervules ' a
cylinder of collected tubes.' I must lay some stress upon
the disposition of this connective tissue, as it is greatly
concerned in some of the morbid changes which I shall
have to describe. If the reader is in any way familiar
with the microscope, he will be able to demonstrate these
details for himself. Let a healthy optic nerve-trunk in
front of the chiasma be taken and soaked for about three
weeks in a light straw-coloured solution of chromic acid.
Thin sections of this are then easily made with a sharp
knife, and rendered transparent by Clarke's or Bastian's
methods 14 . These sections form beautiful objects, and their
variations in disease are very interesting and easy to trace.
The vessels lie in the connective tissue between the longi-
tudinal canals.

From the foregoing descriptions it is clear then that
the optic nerves are far more complex in structure and
arrangement than any other nerves, and should rather be
regarded as commissures or bundles of nervules ; that they
are highly vascular, and are vascular with a vascularity
which is in close relation with that of the brain itself;
that they are very rich also in connective tissue ; that in
their extensions into the encephalic cavity they traverse
the base of the brain in the direction of parts which are
continually liable to disease; that their course up to the
geniculate and quadrigeminal bodies is a long one, and
brings them into near relations with the important organs
of the meso-cephalon ; and that they have central connec-
tions in the geniculate and quadrigeminal bodies, which
centres are again closely related to the cerebellum by the
processus ad testes or superior peduncles, and to the great
strands coming up from the spinal cord.

14 Oil of cloves is better than oil of turpentine in Clarke's process ; it is at
least as efficient, and far more agreeable.

in.] AND RETINA. 37

It is probable that the optic fibres have even more ex-
tensive connections than those which I have indicated con-
nections which have hitherto baffled the anatomist. The
researches of Gratiolet, Schroder van der Kolk, and other
most able investigators, have made it probable, for example,
that some of the optic fibres radiate into the hemispheres,
though they have found it impossible to decide upon the
point. I believe, however, that the ultimate distribution
of the optic fibres is less important to our present inquiry
than is commonly supposed or appears likely.

ANOMALIES OF THE OPTIC DISK AND RETINA.

Before entering upon the chapter of actual disorder of
the optic disk and retina, it is important that the observer
should be on his guard against those insignificant, but
often very striking, variations in the appearance of these
parts, which depend upon mere individual peculiarities, and
have no pathological meaning. Under this head of acci-
dental anomalies, I shall consider the vessels first and the
disk and retina in the second place.

I have said that the distribution of the vessels presents
many differences, so that it may indeed be difficult to find
two eyes exactly alike in this particular. Such variations,
however, are not striking, nor are they likely to be mis-
taken for disease. A tortuosity, which is really a mere
accidental peculiarity, is more likely to deceive, as it may
lead to the inference of over distension of the vessels ; or
a twist or 'kink' in a vessel may simulate a haemorrhage.
This latter mistake is often made, and is as easily prevented
by using a higher magnifier, or by looking at the erect
image. The former is more difficult to guard against, and
it is only after much experience that the observer should
permit himself to express an opinion based only upon lesser
changes in the colour, the size, or the tortuosity of retinal
veins. A skilled observer, by considering all the points
of a case, will know how to give their due weight, and no

38 OPTIC NERVE [CHAP.

more, to such appearances, whether evidences of disease
or mere individual anomalies.

Persistence of the hyaloid artery must be a somewhat
peculiar object, but it has never fallen to my lot to see it.
In the fetus an artery passes from the disk through the
vitreous body to the lens, and in some rare cases this artery,
or its sheath, instead of dwindling away, has been seen
to traverse the adult eye. Laurence describes such a case
in the July number of the 'Ophthalmic Review' for 1865,
and many cases are recorded by German observers 15 . It
is a mere curiosity, and needs no further description in
this place.

Pulsation of the veins is not infrequently to be seen in
a perfectly normal eye. It is a hydrostatic phenomenon,
and is due to the impulse of the retinal arteries which
compresses the vitreous humour, which in its turn com-
presses the veins, so that the venous pulse is synchronous
with the arterial diastole and the cardiac systole 16 . The
same effect may be produced artificially in any normal eye
by slightly compressing the eyeball, and thus adding to
the tension of the vitreous body. In some eyes the venous
pulse is very evident without any extraneous pressure ; but
I believe arterial pulsation is never visible under any cir-
cumstances, natural or artificial. The venous pulse is gener-
ally to be seen in the large branches alone, in those which
lie upon or lie close to the papilla, but in some cases I
have seen it sweeping over all the field of observation.
In the cases of physiological excavation of the disk which
I am about to describe, the pulsation may be well seen
in the bends of the veins as they climb over the edges of
the cup. The stream is of course from the periphery towards

15 Vid. Liebreich, 'Klin. Monatsblatter' for same year, 1865, p. 24; Mooren,
'Ophthal. Beobacht,' 1867, p. 204 (Mooren's case was observed, however,
in 1859) ; and Wecker, ' Annales d'Oculistique,' torn. 53, p. 65.

16 In the 'Arch. f. Ophth.' Bd. III. 2, p. 155, art. 'Bin Mikrometer am
Augenspiegel,' Schneller demonstrates the variation of size in the choroidal
vessels consequent upon changes of intra-ocular pressure. He shows, also, that
atropine causes a diminution of intra-ocular pressure, and thus a distension of
the choroidal vessels. Schneller's views seem, however, open to some question.

in.] AND RETINA. 39

the centre, the dilatation moving in this direction and the
contraction in the reverse.

The excavation of the optic disk, sometimes seen as an indi-
vidual peculiarity, may well be mistaken for commencing
disease, such as atrophy or glaucoma. In the normal eye, as
I have said, there is always a slight depression near the centre
of the disk, at the point where the vessels issue from it, and
in some cases this depression may be so exaggerated as to
become an actual cup. It is best seen of course with the
binocular instrument. Here, again, we have to thank that
successful and accomplished observer, Heinrich Miiller, for
the first adequate description of this peculiarity 17 . This
excavation fortunately never proceeds far, though it fre-
quently presents steep walls. It seldom sinks deeper than
the thickness of the retina and choroid, and never tres-
passes upon the lamina cribrosa ; nor, again, does it ever
involve the whole disk, but preserves its original character
as an exaggeration of the central pore 18 . The excavation
is in some cases accompanied by other inequalities, a part
of the disk being hollowed and another part elevated; or
we may see a sloping wall on the side of the yellow spot,
and a steep wall on the opposite side; or, again, the exca-
vation instead of being circular may be irregular or angular.
The changed colour of the disk in these cases is more striking
than its change of form, and the strong redness of the disk
around the cup contrasting with the white or the grey of
the cup itself, may give a strong impression that disease
is present. I have never seen the vessels bend under the
edge of the cup so as to be lost to observation, as we see
them in glaucomatous excavation, nor have I noticed any
difference in the vessels themselves, except the slight differ-
ence in colour, which of course takes place in consequence
of the changed reflections. These physiological excavations

17 Grafe's 'Archiv.' iv. 2, s. 4.

18 I think it better in these and many similar passages to speak from my
own experience, rather than to copy the statements of others. But I should
say that other observers do describe this cupping as involving the whole disk,
and as pressing beyond the sclerotic. So likewise with arterial pulsation,
which some writers profess to have seen, and may have seen.

40 OPTIC NERVE [CHAP.

should be borne in mind, for I believe they are by no means
uncommon. A friend of mine presents this anomaly in a
marked degree, and I have had his case in mind while
writing the above paragraphs. He narrowly escaped a
terrible prognosis at my hands, for I discovered the state
of his optic disk in the early and innocent stage of my
inquiries.

No less important is it to recognise distinctly those changes
which take place in old age, lest we attribute that to disease
which is due only to lapse of time. In old age tissues lose
their transparency, and undergo even further changes of a
degenerative kind ; the more delicate the part the more ob-
vious, of course, such changes will be. As the skin loses its
brightness and delicate vascularity, so the optic disk loses its
transparency and the tints of its complexion. The dioptric
media become dull, so that the back of the eye is less distinct,
and the tracery of the disk and retina loses the sharpness and
delicacy of its earlier and fresher life. Changes, therefore,
which in youth would lead us to recognise an atrophic or
even a sub-inflammatory process, in age would cease to have
any such meaning. Practice alone can teach us to estimate
these little variations at their true value.

Anomalies in the colouring of the disk. It is impossible to
give any accurate idea of the colour of the disk by verbal
description, nor have I made any serious attempt to do so.
Almost every writer has given his own description of the
tints of the disk, some more successfully, others less success-
fully ; some evidently seeing with the general .eye of man-
kind, others having peculiar visions of their own. But so
many persons talk loosely about the disk seeming too white,
the disk seeming too red, the disk having a bluish tint, or
a grey tint, and the like, that I feel myself obliged here to
show any person how to produce such anomalies of colour at
will. First of all the colour of the disk differs a great deal
in persons of various ages and of various complexions. I have
just described the waning disk of age, and contrasted it
with the fresh bloom of the more youthful nerve; I may
add, that between persons of dark and light complexions

in.] AND RETINA. 41

we may find at least as great a difference. This difference is
due chiefly to the degree of pigmentation in the choroid, and
the effect in the disk is mainly perhaps one of contrast. In
deeply pigmented eyes the disk shines out with a luminous
silver yellow light; while in eyes less rich in pigment the
disk stands out less trenchantly, and usually seems of a red-
dish hue. The kind and degree of illumination again has a
marked effect upon the tints of the disk. The strong yellow
lights so often used, when combined with the bluish grey
reflection of the nerve cylinders in the disk, may account for
the greenish glimmer which some observers have curiously
examined. This hard greenish appearance, which has aroused
suspicions of atrophy in anxious minds, may be cured at once
by adapting a pale blue chimney to the lamp. Again, the
stronger the illumination the nearer in general the disk ap-
proaches to white. The delicate greyish blue so evident in
the twilight of the direct examination, disappears in the glare
of the indirect examination ; under its strong light all deli-
cate tints are banished, and the disk appears white or yellow-
ish or reddish white. Again, in the direct examination the
careful observer will even note changes in colour as he varies
his accommodation. If we do not accommodate exactly for
the surface of the disk, we shall see it uniformly of a bluish,
yellowish or reddish white. But if we adjust our vision very
accurately, and hold the mirror steadily, we shall detect a
great difference between the inner and outer portions of the
disk. Nothing is more common, however, than to see this
difference pounced upon as an evidence of disease ' the inner
half of the disk was seen to be much congested,' &c. In fact,
the colour of the disk is compounded of the colours of its con-
stituent parts firstly, of the connective tissue, which is
formed in the vascular sheath at or near the centre, and in
the underlying lamina cribrosa ; secondly, of the nervules de-
prived of their neurilemma ; and thirdly, of the blood-vessels.
The colour of portions of the disk varies, therefore, with the
various arrangement of these elements. At the centre the
connective tissue surrounding the vessels stands alone, and is
and ought to be quite white. In the inner half of the disk

42 OPTIC NERVE [CHAP.

we have the other extreme. The nervules given off on this
side are far more numerous than on the side of the yellow
spots, and they therefore, together with their fine vascular
networks, conceal the whiter element the connective tissue
in the cribriform plate. On the other side, near the yellow
spot,, there is a much thinner layer of expanded nervules, and
more light is therefore reflected from the white cribriform
plate. So distinct is the cribriform plate on this side, that in
the erect image spots and streaks can be seen which corre-
spond to the canals from which the fibres issue. If we look
perpendicularly into the canals, they appear to us as greyish
dots ; if we look obliquely into them, they appear rather as
oval marks or streaks. In wasting conditions these stip-
plings or streaks become much more evident, and may be
seen in the inverted image. Some rare cases are recorded in
which the disk was of a strange colour, blue, for example,
or red brown, and in which vision was unaffected. When
pigment invades the disk, it is always black, and is probably
accidental. It has rarely happened to me to see it upon the
disk itself; it is generally confined to its outskirts.

There is yet one more striking kind of abnormity in the
fundus of the eye which has often caused much perplexity to
inexperienced observers, and does certainly suggest an alarm-
ing state of disease. I refer to the white patches which are
sometimes seen upon the edge of the disk and invading the
retina. They are not, I think, very uncommon; they may
occur in one eye or in both, and they may be single, or two
or more may be present. They are based upon a segment of
the margin of the disk, and may extend upwards, downwards,
or inwards ; they seldom extend towards the yellow spot, for
reasons which will be evident when we have explained their
anatomy. They shine with a pearly white or greenish lustre,
and have, as v. Recklinghausen 19 says, an asbestos-like appear-
ance, especially in those cases in which they present a striated
character. This striated character may indeed always be made
out by the direct examination, and is an important point in

19 v. Recklinghausen, ' Markige Hypertrophie der Nervenfasern der Netz-
haut.' Virchow's ' Archiv.' Bd. xxx. s. 375.

in.] AND RETINA. 43

their diagnosis. Their borders are jagged or irregular, and
generally shade off a little into the neighbouring retina, which
by contrast appears very red 20 . They do not interfere with
vision ; they are always congenital, and in some animals are
a part of the normal state. In these cases streaks may some-
times be seen along the borders of the vessels; and such streaks,
taken together with the patch or patches, might lead an un-
wary observer to suppose the presence of albuminuric retinitis,
though the appearance is really very different. The vessels
which traverse the white patch stand out, of course, with
great distinctness when they pass over its surface ; when,
however, they pass along in the thickness of the patch, they
are more or less concealed ; or they may pass along at various
depths in its substance, when they appear thicker or thinner
according to the depth at which they are embedded. This
strange abnormity depends upon an extension of the sheath of
the nerves beyond the cribriform plate, the patch being, in fact,
made up of nontransparent insulated nerves. The normal
transparency of the retina, as we know, depends upon the
arrest of the sheaths of the nerves at the optic disk ; and if
the sheaths be accidentally continued beyond this point, we
have an opaque white patch corresponding to the number and
length of the fibres so sheathed. The neurilemma thins off
at the borders of the patch, leaving the axis to pass in the
usual way.

We shall now proceed to the consideration of those changes
in the optic disk and retina which do signify the presence of
disorder ; but I shall confine myself to the changes which
have a symptomatic value. For a description of the changes
which, like glaucoma, are evidences of local disease only, I
must refer my readers to the works of ophthalmic surgeons.

20 Vide Liebreich, 'Atlas,' p. 27. Plate xii. figs, i, 2.

CHAPTER IV.

ON THE VARIATIONS FROM HEALTH OF THE OPTIC
NERVE AND RETINA.

IN this chapter I propose to describe the morbid changes
which take place in the optic nerve and retina, in order that,
when they are themselves fully understood, their connections
with other disorders may be more clearly discussed hereafter.
According to the canon upon which I often insist, we shall
best interpret these morbid states by tracing their origin in
the slightest deviations from health. The first class of changes
I shall describe are those which occur in the circulation, and
which are not attended with any sensible deterioration of
structure ; these we shall not refer to a standard of ' optic
neuritis,' but to the standard of health ; and we shall try to
detect the early and various modes of departure from that
state. After discussing the simple variations in blood supply,
we shall pass on to congestions with effusion, to neuritis and
atrophy.

The parts which we have to watch are the optic disk, the
retina, the choroid, and the blood-vessels. The optic disk is
liable to anaemia, to simple congestion, and to congestion
with effusion within or around it ; to inflammation of its
outer sheath, to inflammation in its substance or inner
sheath, and lastly to atrophy. The retina is liable to serous,
fibrinous, and fatty exudations or patches, more especially in
the course of the vessels ; also to haemorrhages. The choroid

VARIATIONS FROM HEALTH, ETC. 45

is liable to loss or disturbance of its pigment ; also to haemor-
rhages. The blood-vessels are liable to many characteristic
changes to diminutions or obliterations, to dilatations, to
tortuosities, to pulsations, to varicosities, to blood stases,
embolism, and thromboses, to diseases of their coats, and to
rupture. The reader will scarcely expect me to enter into
minute descriptions of these very various states. I shall only
describe the meaning and causation of the chief deviations
from the normal condition. The great variation which is
found even in healthy nerves is one of the difficulties expe-
rienced by beginners in ophthalmoscopy. Let me earnestly
repeat, that many peculiarities which to the unwary observer
appear to be marks of disease, are in no way of evil meaning.
Not only, as I have said, do we find from time to time such
peculiarities as large white patches upon the retina, and white
rings or rings of pigment upon the margin of the disk, which
varieties may be congenital or may be mere harmless changes,
having no special meaning ; but we find variations also in the
colour and vascularity of the optic nerve, which at times may
be puzzling even to a practised observer. There is sometimes
room for doubt whether a deeply coloured disk is due only to
the youth or the complexion of the patient, or whether it be
due to congestion. A pale disk, again, may be pale from
general or local anaemia, or its pallor may be the mark of com-
mencing atrophic change; in one person some largeness of the
vessels and distinctness of the capillaries is a physiological
condition, in another it may be due to pathological con-
ditions. Nothing is more blameable than the off-hand con-
demnation of optic disks as 'too red,' 'too white,' and so on.
To determine the presence of slight congestions in the papillae
is not easy, and can be done only by carefully considering all
the circumstances of the case, by watching its progress, and
by comparing one eye with the other.

In the normal state the eyes are generally alike, but in
morbid states it is rare for the two eyes to advance by quite
equal degrees, though a few instances are recorded in which
one optic disk has been destroyed by atrophy while the other
remained healthy. I have seen this in three cases. In cases

46 VARIATIONS FROM HEALTH [CHAP.

of encephalic disease the disk on the same side as the disease
is sometimes affected first and chiefly.

A. Hyperamia.

The main distribution of the artery and vein of the retina
are tolerably uniform, and as they are very liable to change
in disease it is of great importance that the observer should
accustom his eye to their average sizes, tints, directions,
and frequency at various ages. The colour of the disks
should also be carefully watched in a large number of healthy
persons, so that the eye may not discover signs of morbid
change in normal peculiarities of age, complexion, and other
modifying conditions. Besides the peculiar vessels of the
disk and the peculiar vessels of the retina, there are certain
other vessels which I have been long accustomed to watch
and to describe as the radiating vessels of the disk. They are
in nutritive relations with the disk and also with the retina
and choroid ; and in atrophy of the disk they may be seen to
shrivel, grow tortuous, and vanish, while the retinal artery
and veins are almost unaffected. In states of congestion, on
the other hand, they appear in numbers, and radiate in a star-
like manner from the disk, chiefly on its lateral aspects. They
have few branches or offsets, and in healthy conditions, under
ordinary magnifying powers, the]f are only visible in twos
and threes. Their appearance, therefore, in any number is
significant of slight degrees of congestion.

In the higher and quite unmistakeable degrees of hyper-
semia, on the other hand, we are in danger of confusing the
secondary neuritic processes, which may complicate it, with
descending neuritis. This distinction is, however, at least as
important as the distinction of early hypersemic stages, both
as regards the presence of a certain symptom and its meaning,
and also as regards its danger to vision. In secondary neu-
ritis of the papilla following congestion, the prognosis as to
vision is far more favourable than in ' descending neuritis,'
and in acute descending neuritis more favourable than in
chronic neuritis or progressive atrophy. Simple hypersemia

TV.] OF THE OPTIC NERVE AND RETINA. 47

may occur in the papilla, in the retinal veins, or in both retina
and papilla together, which shows the independence of the two
circulations. At first the leading yessels, and chiefly the reti-
nal veins, grow fuller, darken in colour, and tend to become
a little tortuous, or even varicose. They seldom give way
except in cases of albuminuria; and in these latter cases the
blood effused degenerates more or less quickly, so that the
haemorrhages appear as brownish or whitish blotches or
streaks across or along the course of the vessels. These
marks are very characteristic of that state of the system in
which the small rough kidney is also formed. In retinal
congestion the extremer vascular branches may also be fol-
lowed with greater ease on account of their dilatation and
darker colour ; for the same reason they seem also more
numerous, and the distinction between venous and arterial
branches becomes more difficult. This point is an important
one, for in the hypersemia which occurs in consequence of
disordered accommodation, we have no difficulty in detecting
the arteries, but often rather a greater ease.

To pronounce upon the lesser degrees of hypera3mia must
always be a most delicate and difficult task ; but it is a great
help to us if, as is most usual, we find these changes more
advanced in one eye than in the other ; and Galezowski as-
serts that the eye on the side of the brain mischief is com-
monly the worse an observation which I too have made in
some cases, but which is not, I think, universally true. Pul-
sations, which may sometimes be seen in the veins of the nor-
mal eye, especially if a little pressure be made upon the ball,
are more evident in hypersemic states. Examination by the
direct image is important in these cases. Congestion of the
disks themselves is generally first seen on the inner half,
where the small vessels are more numerous, and from thence
a full red invades the whole papilla. Slight oadema may then
take place, so that its edges are dimmed, and the disk is
veiled by a cloud, or its outline becomes altogether lost, and
its locality known only by the convergence of the veins. In
earlier stages, however, the connective tissue about the vessels
in the centre remains white and strongly contrasted with the

48 VARIATIONS FROM HEALTH [CHAP.

red periphery. Sometimes little dark red spots are seen upon
the angry-looking disk, and are called ecchymoses; when exa-
mined, however, in a larger image, they may nearly always
be resolved into little dilatations or kinks in the vessels. This
kind of disk is quite independent of any hypersemia of the
choroid, and indeed may sometimes occur without much
dilatation of the retinal vessels. The sight may be dimmed,
especially if there be a film of cedema, the eyes may feel
heavy, or the patient may complain of flashes of light, iridic
colours, and the like. Neither these conditions, however, nor
neuritis cause photophobia, which seems to be due to the pain
of movements in the ciliary region and to depend upon the
fifth nerve. We need not fear, therefore, in spite of Jager's
warning, to use a strong light, or to make repeated examina-
tions in this state of the optic disks.

The causes of hyperamia are many. It may be the first
stage of full ischaemia, of neuritis, or of an atrophic process ;
or, again, it may be due to orbital disease, to choroiditis, or to
Bright's degeneration. Slight degrees of it are not uncom-
mon in drunkards ; but in a very great number of cases it
is due to encephalic disease to tumour, to acute or chronic
meningitis, or to changes in cerebral vascularity, which may
be attended with convulsions or mania. The presence of
hyperamic and anaemic conditions of the disk and retina
in convulsive and maniacal diseases is of high pathological
interest. In epileptics I am satisfied that there is a higher
average fulness in the vessels of both disk and retina than in
healthy persons. It is difficult to assert this in any single
case ; but if we take a hundred cases of well-marked simple
epilepsy together, we shall see a higher contrast in the white
centre of the disk, a deeper and perhaps stippled redness of
its circumference, a purpleness and distinctness of the veins,
and a frequency and decision about their smaller branches.
They are seldom tortuous; nor are the outlines of the disk

often obscured, though this was the case in Ann G ,

No. 5, Appendix.

Transient hypersemia may be seen in heart diseases which
obstruct the venous circulation, and in Graves' disease ; but I

iv.] OF THE OPTIC NERVE AND RETINA. 49

do not know how far we may reason from it to the encephalic
condition. In Graves' disease, indeed, the venous turgescence
seems to me more likely to be due to pressure upon the inter-
nal jugular vein. Venous hypera3mia of the retina may be
seen, too, in menstrual disorders. Inquiry must always be
made, therefore, into the state of the heart and other functions
before we decide on the symptomatic value of intra-ocular
congestions.

It is very frequently stated, and stated with a confidence
which is quite unjustified by any complete or accurate obser-
vation, that the sympathetic nerve system is endowed with
great power over the vascularity and nutrition of the optic
disk and retina. Fancies about the sympathetic nerves are
now very fashionable, and their mysterious agency is called
upon every week, every month, and every quarter to explain
all sorts of phenomena, or supposed phenomena, in healthy
physiology, morbid physiology, and therapeutics. The less
the writer and the reader know about the sympathetic nerve
system, the more satisfactory, of course, is the explanation.
It is asserted in most ophthalmic treatises that paralysis of
the sympathetic in the neck causes hypersemia of the optic
disk and retina. This may be so : indeed, I am far from say-
ing that it is improbable ; but, so far as I know, it is wholly
unproven ; nor do I find any proof of this assertion in the
writings of those who repeat it. Bernard certainly says
nothing of the kind ; and in cases where I have been able to
examine the back of the eye during conditions of disorder in
the cervical sympathetic, I have found no consequent hyper-
semia. I have examined the eye carefully with the ophthalmo-
scope in two cases of aneurism al pressure upon the cervical
sympathetic, in three cases in which the cervical sympa-
thetic was paralysed by disease of the neck, in many cases
of Graves' disease, in which latter disease the sympathetic
is said to be at fault, and in many cases submitted to
galvanism of the sympathetic in the neck ; but I have
obtained no constant results. There is sometimes venous
hypersemia in Graves' disease, but this I should refer, as
I have said, to venous obstruction rather than to the paralysis

E

50 VARIATIONS FROM HEALTH [CHAP.

of the carotid. Few conclusions command my wonder more
than the common accusation of the sympathetic nerves in
the so-called { spinal amaurosis.' If the sympathetic can
set up an atrophic process, no douht it may easily establish
hypersemia; but I have yet to learn that there is a single
valuable clinical fact to be adduced in favour of either pro-
cess. Should it turn out that section of the ciliary nerves
prevents the occurrence of sympathetic ophthalmitis, we
shall no doubt have done something to enlighten a very diffi-
cult subject ; but, so far as I am able to tell, the conjunctiva
and cornea seem to be the first to suffer in the implicated eye-
ball, as they are the first to suffer in sections of the fifth nerve.
When I treat of amaurosis in spinal disease, I shall have to
return to this subject.

B. Antemia of the Disk and Retina

is the opposite of hypersemia, and depends upon an emptiness
of the vessels. I am sorry to see many authors whose words
have weight using the word 'anaemia' when they mean, or
may mean, atrophy of the disk. It is of great importance,
both for the physician and for the ophthalmic surgeon, to
distinguish the two states, nor do I think it is often difficult
to make the distinction. Anaemia of the disk is nearly always
accompanied with anaemia of the retina and choroid, so that
anaemic eyes light up badly ; while in atrophy of the disk the
choroid may be of healthy brightness. The retinal vessels,
too, in anaemia, are shrunk' shrunk to a degree we should
not find in commencing atrophy 1 , and an anaemic disk never
has the hard, sharp, staring look of atrophy of the third de-
gree. In atrophy of the first and second degrees, if subsequent
to neuritic changes, the retinal vessels would be rather swollen
than collapsed ; and in anaemia we seldom or never see the
vessels standing out so distinctly against the paling back-
ground of the disk as we see in atrophy. In anaemia, too, it

1 There are some good drawings of the anaemic fundus in the Library at
Moorfields. In one case the anaemia was connected with irregular menstrua-
tion, in the other with oversuckling.

iv.] OF THE OPTIC NERVE AND RETINA. 51

is generally possible to distinguish the arteries from the veins,
which distinction, in atrophy, is more commonly lost. Again,
the edges of the disk in anaemia are not so sharp as in early
simple atrophy, the fibrous extensions to the retina remain
uninjured, and under a good light, and with four or five-inch
lens, a fibrous texture may, in anemia, still be detected ; the
more as I think there is often a slight oedema in anemic disks
making this coarseness of texture more evident from the
swelling of the nerve filaments. The oedema also gives a
greyish look to ansemic disks. These phenomena, however,
are studied best in the erect image 2 .

In atrophy the nerve fibres waste, and are replaced by con-
nective elements. Atrophy, again, is generally unequal on
the two sides, while anaemia is equal ; and atrophy does not,
as a rule, begin all over the disk at once, but invades the disk,
as the arcus senilis the cornea, or works across from the outer
to the inner moiety. The subjective symptoms, too, are gene-
rally different. In simple atrophy we are told of a gradually
increasing amblyopia, attended with scotomata ; in anaemia,
of capricious fits of darkness of sudden blindness on rising
from bed, for instance relieved by intervals of fair sight,
and instead of scotomata we hear of flashes of light, sometimes
of a most painful intensity, or of ' muscae volitantes.' The
field of vision, again, in atrophy nearly always contracts from
the internal side ; in anaemia there is uniform feebleness of
vision all over the field. These considerations, taken together
with the history of the case and its general symptoms, will
always, I believe, help us to a pretty certain conclusion.

The causes of an&mia of the disk and retina are the same as
those of general or local anaemia, or the anaemia may be due
to vascular spasm. Cases 6, 13, 14, 18 in the Appendix are
good examples of anemia. We must be careful to remember
that transient blindness or dimness may be due as well to
transient anaemia of the perceptive centres as to anaemia in

2 I must warn the inexperienced observer that the retinal vessels, when
seen against a whiter disk, appear larger by contrast. Allowance must be
made for this, and, after some practice, such allowances are made almost
unconsciously.

E 2,

52 VARIATIONS FROM HEALTH [CHAP.

the eye. The dimness of vision which often occurs during
aortic regurgitation may be due to either or to both states.
I have often seen anaamia of the eye in these cases. In some
cases, again,, we seem to have an epilepsy of the function of the
retina due to anaemia, as we have epilepsy of the function of
the corpus striatum in animals bleeding to death, and as we
have an epilepsy of the mental function in mania. I have now
a man under my care who is subject to epilepsy, and who has
( fearful flashings of fire ' in his eyes by way of warning.
Dr. Hughlings Jackson also has published such cases, which,
in fact, have been noticed from the time of Aretaeus. The
occurrence of vascular spasm and paresis in a visible part like
the eye is, if finally ascertained, a fact of very high interest,
as it would raise our notions of a like morbid process in the
brain from a probable hypothesis to a very safe inference. In
its effects upon function, venous hyperaemia is very similar
to anaemia. I have given in the Appendix a case of convul-
sion during which I found a hypersemic state. [Case No. 5.]
I found the reverse condition in another case in which I
watched the disks and retinas during a long-continued status
epilepticus. In this there was marked anaemia of the disks,
trespassing a little upon the neighbouring fibrous coat of the
retina, and Mr. Carter tells me that in such a case he once
noted the same appearance.

I believe that there is an important distinction between
partial and complete anaemia in these cases. Complete anae-
mia, as in embolism, will probably abolish function, while
partial anaemia, due to vascular spasm, to bleeding, to pres-
sure, &c., allows of the accumulation of force at a low tension,
which is irregularly discharged as energy. So it is also with
partial and complete degrees of venosity of the nutritive
blood ; but to this interesting question I must return at
another time.

C. (Edema of the Disk.

Of simple osdema of the disk and neighbourhood I have
seen little or nothing, but the subject is one of some interest.
(Edema very often occurs as a complement of other affections,

iv.] OF THE OPTIC NERVE AND RETINA. 53

as, for instance, of neuritis, of anaemia, or of embolism of
the central artery ; in neuritis, indeed, it plays a considerable
part, and is the cause of that ' woollinesg ' which Mr. Hutch-
inson often describes. It has never happened to me, how-
ever, to see oedema as a substantive disorder. Manz 3 speaks of
the occurrence of enormous dropsy of the nerve-sheath in some
cases of optic neuritis, or rather of ischaemia papillae (vide Case
No. 34, App.), but does not speak of it as existing alone.
The most interesting observations upon this subject which I
have met with are by Macnamara, who relates in detail
a case in which oedema of the disks was a prominent and
most important symptom 4 . The patient was a little girl
aged thirteen, who had suffered from quotidian ague. As
the ague disappeared under treatment, she became palsied
of all four limbs, of three limbs completely and of the left
arm partially. Reflex action remained, and there were no
abnormal sensations. There was no disease elsewhere, except
an enlarged spleen. So far, the case might well have been
one of so-called hysterical paralysis; but the state of the
disks contradicted such a diagnosis. With the access of
the palsy there appeared also some dimness of vision, which
rapidly advanced to blindness, with dilatation of the pupils.
With the ophthalmoscope there was found no neuritis, no
retinitis, no atrophy, no haemorrhage, no interference with
the arteries or veins, but there was great oedema of the disks.
Macnamara assumed that there was a similar state of serous
effusion without structural mischief in the centres of motion ;
and the results justified his assumption. Under the use of
iodide of potassium with strychnine and arsenic, the girl
made a perfect recovery in a short time, her sight and
motion being quite restored. Macnamara has noticed these
conditions more than once, and believes that malarious dis-
order is a disposing cause. A like state of things seems
to occur in the horses and cattle of Western Europe. A
very intelligent and skilful veterinary surgeon, Mr. Fearnly,

3 'Kliniscbe Monatsblatter' (1865), p. 283; quoted by Mauthner, ' Lebr-
bucb/ p. 290.

4 'Medical Times and Gazette,' May 2, 1868.

54 VARIATIONS FROM HEALTH [CHAP.

of Leeds, tells me that by reading my papers on the use
of the ophthalmoscope, he was led to use the instrument
in the nervous diseases of animals, and has obtained some
valuable results. In particular, he tells me that in several
cases he has met with simple oedema of the disk and neigh-
bourhood, coinciding with curable palsies of the limbs. Two
cases he related to me which much resembled Macnamara's
case, and in them also he obtained a speedy recovery by the
free use of iodide of potassium. Mr. Fearnly had not met
with Macnamara's remarks, his own observations being quite
original.

D. Ischcemia of the Disks. (Choked disks 5 .)

Before I had long used the ophthalmoscope in cerebral
disease, I began to entertain serious doubts about the true
neuritic origin of many extreme disturbances of the disks.
I gradually became assured that many of the worst cases
of so-called optic neuritis are really mechanical congestions
or venous arrests, differing essentially and importantly from
inflammations. I attributed this stoppage to pressure upon the
cavernous sinus, and supposed that such pressure would account
for all the phenomena. I afterwards read the well-known
paper by Grafe ('Arch. Ophthalm.' 1866, ss. 114-119), where
this great oculist proves that congestion and swelling of
the disks with effusion are often due to vascular arrest
alone. He points out, however, that this could not result
simply from obstruction in the cavernous sinus, but must
depend upon the concurrent action of the sclerotic ring.
We have just seen that this unyielding ring so accurately
fits the nervo-vascular trunk which traverses it, that when
the slightest venous arrest distends this trunk, its embrace
becomes a strangulation. He shows, accordingly, that these
congestive affections of the disk are in the first place, or
are throughout, confined to that part. [' Beschranken sich
die Veranderungen (starke Schwellung und venose Stauung)
nur auf das intrabulbare Sehnervende.'] Many of our de-

5 Vide Liebreich, 'Atlas,' Tab. xi. fig. 2, and the frontispiece of this volume.

iv.] OF THE OPTIC NERVE AND RETINA. 55

scrip tions of * optic neuritis' have been taken from this state
of strangulation, which I would propose to call 'ischsemia
papillae.' This action of the sclerotic ring enables us to
form most accurate opinions upon degrees of pressure within
the skull, as, to use Grafe's happy expression, f it plays
the part of a multiplier' placed upon a vascular offshoot
of the brain. Ischsemia of the disks may often, but cannot
always, be distinguished with the mirror from optic neuritis,
as the two are frequently associated. I shall compare the
two conditions when we come to 'optic neuritis/ and shall
now try to describe simple ischsemia papillae in the third
degree. The trunk of the nerve is unchanged, and all the
morbid signs are confined to its intra-ocular termination.
This part, we see, is greatly swollen, and it generally rises
steeply on one side, and sinks gradually to the level on
the other. A skilful observer will be able to detect this
projection of the disk, both in ischsemia and neuritis, by
the shortening of the axis of the eye in this direction. Such
projecting disks may often be seen, as in hypermetropia, by
the mirror alone. There is some swelling also of the fibres
themselves, so that they lose their transparency, and the
papillary region looks more coarsely fibrous than in health.
Its colour is often a mixture of dirty grey and red, due
to the mingling of passive effusions with distended capil-
laries and haemorrhages, but in other cases there is not
much extravasation of blood, and the protruded disk looks
bright or almost transparent.

Small patches of extravasation from rupture are, how-
ever, commonly found in numbers upon the disk. The
morbid appearances trespass a little, but not far, upon the
retina, seldom to a distance of more than half the diameter
of the disk. The margin of the disk is wholly concealed
by infiltration; by excessive vascularity, which gives it a
mossy appearance; and by the coarsened fibrous extensions
to the retina, which in the erect image give a striated
quality to the disk and the peripapillary halo. The opacity
of the retina rapidly ceases from this point, and there are
no films or degenerative patches beyond, except perhaps

56 VARIATIONS FROM HEALTH [CHAP.

streaky exudations in the course of some of the larger
veins. The veins of the retina are enlarged, sometimes
enormously, and they tend to become very tortuous both
in the plane of observation and from before backwards;
they may also be very varicose. I have never seen them
ruptured in ischemia, nor are they so much concealed by
exudation as they are in neuritis. I have twice examined
disks in this state after death with the microscope,, and
have found them to be as described by a few other observers.
The disks are enlarged and thickened, and the swelling
and thickening extend more or less into the fibrous and
other layers of the retina. There is exudation into the
substance of the disk, and its vessels are enlarged, distorted,
and in many places thickened. There is some cell and
nuclear proliferation in the course of the vessels, and in
the cribriform plate. In the fibrous layer of the retina
may be found the homogeneous bodies without limiting mem-
brane or nucleus, which probably result from the breaking
up of nerve tissue 6 . A very interesting examination was
made by M. Cornil upon a case under the care of M. Vigla.
The case was one of encephalic tumour, in which the worse
symptoms had rapidly developed themselves, and the disks
had not, in all likelihood, been long congested. M. Cornil
found only a prominence of the disks, serous infiltration
of the connective tissue, and a few small haemorrhages 7 .

The extra-ocular parts of the optic nerve are normal.
What we find, then, is some ' inflammation ' of the disk
and retina immediately around it, as shown by proliferation
of cells from the neurilemma and the sheaths of the vessels,
and development of new vessels, with disintegration of nerve
fibres. Nor is this contrary to expectation. I do not hold
with Grafe that this inflammation results from the greater
susceptibility of the congested structure to ordinary 'irrita-
tions/ nor that the extravasations of blood are ' foreign

6 Virchow's examinations in Grafe's cases are to be found in the paper
to which I have referred. See also Samisch, ' Beitrage zur normalen u. path.
Anat. des Auges.' Leipzig, 1862.

7 'Arch. Gen. Med.' (Dec. 1868), p. 679.

iv.] OF THE OPTIC NERVE AND RETINA. 57

bodies ' and sources of local ' irritation/ I think it better
to say that the ' inflammatory products' are due, first,
to the great disturbance or arrest of nutritive relations,
and, secondly, to mechanical lesion followed by greater or
less resistance. Sir W. Jenner very well describes the
sub - inflammatory results of congestion of tissues in his
paper upon ( Congestion of the Heart 8 / The irritation at
the disk is sometimes propagated beyond the lamina cri-
brosa up the orbital portion of the nerve, making a ' neuritis
ascendens.'

It is astonishing how changed and disfigured the optic
disk and neighbourhood may become in this affection without
disturbing central vision. I have lately had several such
patients under my care who could read a badly printed
news-sheet with ease. The same fact is strongly insisted
upon by Grafe. For this reason the condition is constantly,
I may perhaps say generally, overlooked, unless it should
happen to come before an ophthalmic surgeon. The pro-
gnosis as to sight is also better than in descending neuritis,
but both affections point too surely to serious encephalic
mischief. The microscope shows, however, that in ischsemia
many more nerve fibres retain their continuity than is the
case in neuritis 9 .

The causes of ischtemia papillaris are all those changes
within the skull (I shall omit all discussion of orbital causes 10 )

8 <Med. Chir. Trans.' vol. xliii.

9 The causation of ischsemia has been much discussed in the German peri-
odicals since the above was written, especially by Hermann, Schmidt, and
Schwalbe. See, particulai-ly, an arti9le by Schmidt in the 'Arch. f. Oph.'
vol. xv. Part 2, pp. 193-197. Schmidt denies Schwalbe's statement (vide p. 35)
that injections of the arachnoid space fill the capsule of Tenon ; and still less,
he says, do they fill any perichoroidal space. He asserts, however, that they
do fill the intravaginal space of the optic nerve, and that the injection there
empties itself into a ' canal system' which ramifies in the lamina cribrosa. He
concludes therefrom that the Stauungs papilla arises from increased intra-
ocular pressure, due to Stauung of the injected fluid in the canal system con-
tinuous with the arachnoid cavity. These observations need verification, but
if proved are singularly interesting, as showing the connection" between affec-
tions of the base of the brain and congestions of the disk.

10 Mr. Salter, in the 'Med. Chir. Trans.' and 'Guy's Reports,' has given
some most interesting cases of amaurosis following inflammations arising in

58 VARIATIONS FROM HEALTH [CHAP.

which more or less directly distend the ophthalmic veins.
Distensions which, in other veins or in other branches of
the ophthalmic vein, would be scarcely noticeable, are, by
means of the multiplying 1 action of the sclerotic ring, made
very manifest in the branches of the retinal vein, and
present the appearances I have described. The three main
causes of ischsemia, with the subsequent atrophy, are :
(i ) meningitis; (2) hydrocephalus ; (3) tumours. It seldom
or never results from acute or chronic softening of the
cerebral substance, from hemorrhage, from sclerosis, or from
arterial degenerations. It probably occurs in caries of the
base of the skull, though I have not seen it : I have
always seen neuritis in these cases. As, however, the
causes of ischaemia may also be causes of optic neuritis,
I shall now proceed to describe optic neuritis.

E. Neuro-retinitis n .

I will now ask first, what * optic neuritis' means as a
name ; and, secondly, whether that meaning includes all
the kinds of change attended with increase of vascularity
to which the optic disk is liable. Now, if our medical
terminology be worth anything, { optic neuritis' should
mean, or rather should answer to, inflammation of the
optic trunk. What, then, is inflammation of the optic
trunk ? or, in the manner of Pilate, what is inflammation ?
Surely the conception of the movement known as inflam-
mation, or which alone ought to be known by that rather
objectionable name, is sufficiently simple. In lectures, I
am wont to define 'inflammation' as lesion with reaction or
resistance. This excludes all transient disturbances of mole-
cular tension, without disintegration. The idea of inflam-
mation must start from a rupture of continuity, however

tne jaw. He asks how the atrophy is caused, and I hope that the foregoing
explanation of the strangulating power of the sclerotic ring may make this
clearer.

11 Vide Liebreich, 'Atlas,' Tab. xi. fig. n ; cf. also Tab. viii. fig. 6.

iv.] OF THE OPTIC NERVE AND RETINA. 59

minute, and we must regard the subsequent congestion
and other phenomena of resistance as secondary. Resist-
ance will manifest itself in various ways, according to the
conditions of the ruptured tissue. When this is surrounded
by vascular and nervous connections, we shall observe not
only cellular resistance, but also nervous and vascular re-
sistance. We shall see proliferation, congestion, and heat
in their various degrees, according to the complexity of
the part which suffers. Vascular extensions do not make
inflammation any more than the railways of the force in
Abyssinia made the war ; they are merely the evidence
of lesion, and the conditions of resistance to it in tissues
of a given complexity. And yet all severe congestions
of the optic disk, with their consequent effusions, are called
optic neuritis ! The truth is, we cannot shake off our
ontological conceptions of a ' nature/ an entity, I believe,
of the female gender, who is always planning something
in the human body ' eliminating morbid poisons,' plugging
up inappropriate perforations, f setting up inflammatory ac-
tions,' and so on. It is really time we avoided all this
reasoning from final causes, and that we sincerely regarded
the functions of tissues as the evidence of an equilibrium
mobile which possesses greater or less powers of resistance
according to its tension, and which manifests such resistance
variously according to its complexity.

If we pass a ligature round the ophthalmic vein, we
produce thereby great congestion of the optic nerve behind
the ligature, and an escape of the vascular contents, due not
to increased attraction on the part of the tissues, but to
mechanical causes, causes like those which, in slates of portal
obstruction, favour an escape of serum into the peritoneal
cavity. I have described this change as ischaemia papillae,
and it is not only incorrect, but very misleading, to call this
result ' optic neuritis/ Injury to tissue is not the starting-
point of the disturbance, though, of course, a secondary
neuritic process with increased proliferation of the connective
elements may be set up in consequence of the pressure.
This is no idle or merely verbal distinction. I have pointed

60 VARIATIONS FROM HEALTH [CHAP.

out in the section upon papillary ischaemia that severe discal
congestions, not neuritic in nature, are common commoner
perhaps than true neuritis and as the nerve tubes may be
little injured, it may cause but little alteration of vision.
Such states, therefore, are seldom presented to the ophthalmic
surgeon, and are to be discovered rather by the physician,
whose mind moves in the opposite direction. In true ' optic
neuritis,' on the other hand, the connective elements suffer
first, and the subsequent congestion is slighter in degree,
though the vision, for obvious reasons, may fail sooner.
True optic neuritis, however, may go far without fully
arousing the patient's attention.

One main distinction between ischsemia and neuritis optici
is, that while the former affection is, as I have said, confined
to the disk, the latter affects the nervous trunk in a greater
or less part of its length. It is, therefore, often called de-
scending neuritis. This process is one of very great interest
to students of nervous diseases. In it we see the mode of
inflammatory destruction of nervous tissue, and from it we
may draw some valuable inferences as to the mode, the rate,
and the propagation of like changes within the cerebro-spinal
cavity or in the course of other nerves. The reader is no
doubt aware, for example, that secondary neuritic changes
have been found in the nerves supplying the limbs in some of
those cases where paralysis has been followed by contraction.
In descending neuritis the connective tissue of the nerve is
probably the active agent, the nervous elements suffering by
implication. In the eye the vascular changes are secondary,
and in uncomplicated neuritis there is no pressure upon the
cavernous sinus. In meningitis, however, neuritis optici is
often complicated with, or preceded by, ischsemia, as the
inflammatory change may invade both the nerve and the
membranes which form the sinus, so that it becomes choked
with coagula or by the accumulation of exudative products
above it, and a differential diagnosis becomes impossible.
Pure neuritis presents the following appearance the nerve
is swollen, but less so than in ischsemia, and it does not
present that steep elevation of one side so characteristic of

iv.] OF THE OPTIC NERVE AND RETINA. Gl

ischaemia 12 . The vessels, again, are of somewhat different
appearance. There is not the same bursting into view of
a multitude of minute branches and capillaries which may
give so mossy a look to ischaemia. The distension in neuritis
is more an enlargement and tortuosity of the main trunks,
though of course there are many more vessels to be seen
than in health. As in ischeemia, the arteries become thin
and indistinct, and there may be numerous minute haemor-
rhages in and near the disk. The colour of the parts, again,
is distinctive in well-contrasted cases. In neuritis we do not
see a circumscribed intense redness or brownish -grey, but
rather a wash of reddish-lilac, or a grey tint, and the tint,
which is more uniform and more opaque, also extends more
widely upon the retina than in ischaemia, and conceals more
or less even of the large veins which converge towards the
disk. The vessels, especially the veins which lie deeper em-
bedded in the dense new formation, dip in and out or dive
wholly out of sight for more or less of their course. The
parts often have, too, what Mr. Hutchinson calls a ' woolly '
appearance, due perhaps to oedema. Grafe considers that this
neuritis is not confined to the fibrous layer of the retina,
but that all its coats are affected. He rests this belief upon
the persistence of white patches, the implication of the yellow
spot where the fibrous coat is not, and on microscopical re-
searches. I have certainly seen in two cases a general
retinitis depending upon cerebral disease. In some cases
of neuro-retinitis the haemorrhages bear a great proportion
to the other changes, so that the disk and neighbourhood
have a very bespattered appearance in the earlier stages,
and in the later ones there are numerous white spots and
other marks of much strife about the stricken disk. I believe
this form is not a separate process, but depends in some cases,
perhaps, upon the co-existence of extreme intracranial pres-
sure, as in tumours of the middle fossa, and in others upon

12 These swellings, making the disk actually a papilla, are best seen with a
binocular instrument. A skilled observer will estimate them in the erect
image by slightly varying his concave lenses, and after some practice we learn
to infer their^existence in the inverted image by the disturbed reflections.

62 VARIATIONS FROM HEALTH [CHAP.

the ready yielding of diseased vessels, as in the optic neuritis
of the senile periods.

The microscopical appearances of optic neuritis are very
uniform, and the opportunities of examining nerves in this
state are not infrequent. Neuritis is by no means confined
to the optic nerves, but is to be seen in many other nerves,
both cranial and spinal. I have in my own possession 13
sections of almost all the cranial nerves exhibiting neuritic
change; the only differences between them rest upon the
various degrees of richness in connective tissue, upon the
rate of the neuritic or sclerotic process, and the amount of
fatty degeneration of the nerve tubules and other products
which accompany it. Changes of this kind have been
described as occurring in the great nerves of the limbs,
especially in cases of contraction of the limbs after paralysis,
and after wounds or injuries. One of the most striking
specimens of neuritis which I now call to mind, is a case
of neuritis of the median nerve in the hand, which is shown
in .the Schroder van der Kolk collection in the Oxford
Museum. In this most interesting case the hand had been
amputated after mischief had been going on in the wrist
for two years. The median nerve is thickened, irregular
and sclerosed, and the neuritic process has descended as far
as the digital branches. This tendency to propagate itself
along the sheath of a nerve is very characteristic of neuritis,
and it is by means of this property that neuritis occurring
in any encephalic portion of the optic nerves, sooner or
later presents itself in the eye. In the optic disk we find
the sheath of the vessels much condensed and thickened,
and evidences of interstitial inflammation in abundance.
If we examine the sheath of the trunk, we find it full of
proliferating nuclei and young cells of great instability. In
the later periods the nerve columns may be seen to have
wasted, and the connective tissue to be considerably increased.
This sclerosis, which also affects the vessels of the disk, will,

13 I have also to thank Mr. Hulke for opportunities of observing some beauti-
ful sections of optic neuritis prepared by himself. There is a good description
of these pathological changes by Virchow in Grafe's ' Archiv.' xii. 2, p. 117.

iv.] OF THE OPTIC NERVE AND RETINA. 63

I think, explain the comparatively little congestion in neu-
ritis. Iwanow has shown that 'perivasculitis' often extends
for some distance along the main trunks, and is visible
as a streaking along their course 14 .

The nerve is always affected in its entire thickness, and
inflammation in one nerve invariably crosses over the chiasma,
and involves the other likewise.

The cause of optic neuritis, when this depends upon
encephalic changes, is meningitis or encephalitis. Optic
neuritis does sometimes occur as an independent event of
obscure causation, or it comes as a consequence of orbital
mischief; but we have now only to deal with it as a symptom
of head mischief, and as a symptom it signifies inflammation
of some encephalic tissue, of membranes more commonly, of
nerve masses less commonly. Optic neuritis is most common
in those meningeal inflammations which, like the syphilitic,
have the favourable conditions of contiguity, duration, and
activity. A chronic meningitis lying at or near the base
of the skull, and marked by active proliferation, is tolerably
sure to set up optic neuritis. Inflammations which, like
the tubercular, are contiguous to the optic tracts and nerves,
and active in changes, but of short duration, cause optic
neuritis as a fact, but not so constantly as a symptom, for
the neuritis may not have time to reach the disks. As
there is generally much exudation, and, moreover, much
ventricular effusion with tubercular meningitis, we more
frequently see hypersemia and actual strangulation of the
disks ; or we see these phenomena at first, with optic neu-
ritis as a later event. We do not see optic neuritis as a
consequence of inflammations, such as traumatic meningitis,
on the upper brain, as these inflammations, though active,
and sometimes prolonged, are not contiguous. Ischaemia
is more commonly the consequence of intracranial tumour
than optic neuritis, and is due to pressure; optic neuritis
does, however, occur no doubt as a symptom and consequence
of tumour, and when it does so is due to meningitis or pos-

14 Cf. 'Iwanow ttber Perivasculitis/ in Zehender's ' Monatsheften/ Sept.
1865.

64 VARIATIONS FROM HEALTH . [CHAP.

sibly to a belt of cerebritis which surrounds the tumour, and
makes its way along the optic tracts or nerves. Unfortunately,
almost all observers confuse optic neuritis with ischsemia, and
we are unable from their words to say whether the disk was
significant of disturbances of pressure or of disturbances of
nutrition. From their descriptions, however, we may often
see that what they call optic neuritis was really ischsemia
papillae. Mr. Hulke, on the other hand, has been very careful
in preserving the distinction in the cases which he has recorded
and classified. Those encephalic diseases which do not cause
optic neuritis are sclerosis, haemorrhage, and simple softenings
of all kinds which are rather attended with atrophy. Abscess
may cause optic neuritis in rare cases when it is of long dura-
tion, surrounded by widening irritations and in contiguous or
connected parts. Periostitis I include in meningitis.

F. Chronic Optic Neuritis,

or ' red softening' of the optic nerve, is a term I wish to
introduce as a name for certain lesser degrees of resistance
to destruction which often precede white atrophy, and which
are constantly overlooked. They are attended with conges-
tive appearances, with very slight or, it may be, with no
effusion, with feeble proliferation, and with but little disturb-
ance of the central vessels. When I began to examine all
cerebro-spinal cases with the mirror as a matter of routine,
I quickly found that many states of the eye called { simple
progressive atrophy' had a distinctly hypereemic stage, with
sometimes a little effusion, preceding the whitening stage.
This certainly has not been described in the eye-books gene-
rally, but I find it described by Mr. Hutchinson in the ' London
Hospital Eeports,' vol. i. In a very interesting paper on
amaurosis, he says, in respect of the white atrophy, which he
is disposed to attribute in some degree to tobacco smoking
* In this form of amaurosis the ophthalmoscope reveals to us
remarkable and very constant conditions. In the early stage
the optic disk is usually too red, and the whole of the choroid
full of blood, and presenting the appearance of a pile of red
velvet. There are no ecchymoses, nor any effusions of lymph.

iv.] OF THE OPTIC NERVE AND RETINA. 65

In a little time the congestion of the optic disk diminishes ;
instead of being too red, it is too white. At this stage the
arteria centralis retinae is much lessened in calibre, but its
accompanying vein is of normal or even increased size. From
this stage outwards the optic disk gets whiter and whiter,
until all traces of arteries, excepting the larger trunks, are
lost ; sometimes, but very rarely, even the largest cease to
be visible. At this latest stage the veins are usually very
small, but I have never known them absent. Whether the
stage of preliminary congestion is always present or not, I do
not know, since a large majority of cases come under notice
long after it is passed.' I have little to add to this descrip-
tion by Mr. Hutchinson of a process which I have watched
in all its stages in such cases as general paralysis As to the
haemorrhage, I may say that the capillary congestion of the
disk seems, in many cases at least, to break up into a minutely
haemorrhagic condition, the capillaries seeming to give way,
and their contents to be extravasated, so that the carmine
passes into browner shades, and the disk at the end of the
congestive stages appears smudgy, or as if stippled with
dirty brickdust. One sometimes sees these appearances like-
wise in the brain in cerebral softening. I have observed
again, in many of these cases, effusion to slight but decided
degrees effusion distending and blurring the nerve, or even
spreading beyond it. For instance, it was present in Case
No. 105 of the Appendix a case of ' locomotor ataxy/ in
which the amaurosis is always supposed to be of the simplest
progressive kind. In that case there was no complaint of
loss of vision. This most uncertain symptom seldom sets in
until atrophy is well forward, as we see also in general
paralysis. To base any inferences, therefore, as to the states
of the optic disks upon degrees of vision, is simply a waste of
time.

Chronic neuritis or softening is not associated with peri-
neuritis, that is, with extension of inflammation upon a belt of
the retina. I have only once examined the structure of the
optic nerve in the red stage of chronic neuritis, but in that
case I did not find any marked proliferation of nuclei from

66 VARIATIONS FROM HEALTH [CHAP.

the neurilemma. I found dilatation of the capillaries, vari-
cosity, and breaking up of the fibrils, a good deal of granular
matter and some nuclei, probably from the interstitial con-
nective tissue. We want, however, many more examinations
of the nerves in this state. I have examined a very large
number of nerves in full atrophy after chronic neuritis. The
nerve fibres are generally destroyed, a few only perhaps re-
maining entire; the vessels are often degenerated or thickened,
and the rest of the trunk is made up of granular matter, oil
globules, colloid bodies, &c. There is, in fact, a degeneration,
with very slight evidence of vasculo-cellular resistance. The
causes of chronic neuritis remain very uncertain. It is not
due to meningitis, as there is no ischsemia nor acute neuritis
with implication of the sheath. I think tumour is always
followed by ischsemia, by acute neuritis, or by simple atrophy
due to disconnection from the optic centres, and not by chronic
neuritis. Perhaps we may see chronic cerebritis around a
tumour or clot propagated as chronic neuritis to the optic
nerve, though I have not traced such a process.

Generally speaking, indeed, microscopic experience leads me
to say, that whenever irritation is propagated along the optic
nerves from inflamed brain or membranes, there is a propor-
tionate degree of proliferation of the connective tissue, and I
shall point out in my next chapter that chronic optic neuritis
is best seen in the three kinds of sclerosis which are known
clinically as general paralysis, locomotor ataxy, and palsy with
tremor, and in the diseases allied and connected with these
by processes which present intermediate characters.

G. Retinitis,

the condition which at the outset is marked by hypera3mia
both of the disk and retina, and afterwards by the appearance
of silvery patches of exudation upon the retina, is an affection
too well known to need any description from me at present.
Of course we must not confound this condition with the retina
of albuminurics. In some ophthalmic works I have been sur-
prised to find that retinitis f is frequently the result of cerebral

iv.] OF THE OPTIC NERVE AND ME TIN A. 67

disease.' Now, out of perhaps one thousand cases of cerebro-
spinal disease, of which I have ophthalmic notes, I have found
general parenchymatous retinitis in two only. In one of these
cases, the retinitis was kindly watched for me at short inter-
vals by my friend Mr. Oglesby. See Appendix, Case 39.

H. Perineuritis 15 .

I accept this name from Galezowski, though there is
no real distinction between it and interstitial neuritis, in
which there is always more or less perineuritis. In some
cases, however, probably of slow change, the inflammation
seems to affect the outer neurilemma more severely, and
to extend over a wider belt of retina. I have not had
such parts under the microscope, but I conceive that we
should find great proliferation around the nerve and less
change in the interstitial connective tissue. Galezowski, who
alone has used the word perineuritis, says : ( The papilla is
prominent and enlarged, but one readily sees with the oph-
thalmoscope that all the exudation is confined to the margin
of the papilla, the outlines of which are veiled, while the
central parts are transparent and more like the normal state.
The capillaries are only developed at the periphery of the
papilla; the central vessels are varicose, and sometimes bor-
dered by an exudation.' He says this form is often con-
founded with the albuminuric neuro-retinitis, and this mistake
might easily have been made in a case of scarlatinal kidney
which Mr. Teale showed to me a few months ago. In the
rest of his paragraph and in his pictures Galezowski is not so
accurate, as he fails to distinguish between optic neuritis and
ischsemia. His picture of perineuritis is more like neuritis,
and his picture of neuritis is clearly from a case of ischaemia.
I do not think there is much to be gained by the name ' peri-
neuritis,' and prefer to include it in neuro-retinitis.

15 This section I leave as I wrote it, though I am tempted to cancel it.
Physicians who use the ophthalmoscope will probably find, as I found, that
our earliest tendencies are to multiply subdivisions, but subsequently to learn
that such subdivisions do not correspond to any essential distinctions. Nay
more, that ophthalmic appearances are so variable that it is difficult to make
classes to include all cases.

68 VARIATIONS FROM HEALTH [CHAP.

I. Consecutive Atrophy 16 .

I will now describe the kind of atrophy in which ischsemia
papillarum and optic neuritis may end. Dr. Hughlings Jack-
son has made popular a certain distinction between an atrophy
following neuritis and an atrophy not preceded by neuritis.
The former, or * consecutive atrophy/ he would distinguish by
the raggedness of its edges and the blurring of its outline ;
the other ( simple or progressive' atrophy he would distin-
guish by its more brilliant appearance and by its clean-cut
even rim. Galezowski, too, distinguishes consecutive atrophy :
' qu'elle est caracterisee par les contours irreguliers, franges,
mal limites, du disque optique,' etc., and the distinction is
very commonly accepted among ophthalmic writers. Now,
although this distinction is, or has been, valuable in drawing
attention to the modes of atrophy, yet I think it is only
partially true. The simple even atrophy often succeeds a
chronic neuritic process, and, on the other hand, the ragged
atrophy following acute neuritis sooner or later loses its blurred
and irregular features, and settles down into the even staring
state which, I think, is the end of all atrophies. The more I
see of the histories of ' simple white' atrophies, the more I am
assured that these states are often preceded by ischamic or
neuritic processes. In tubercular meningitis, for example, I
have on my notes cases illustrative of every phase of the eye
symptoms. In them I find that the most violent ischsemia or
neuritis, which passes into the transition atrophy (as I would
call it) the ragged state with swollen retinal veins and exu-
dative patches grouped about the margins does also ulti-
mately settle down into the even-edged and staring form.
This kind of amaurosis, which I have found so often in blind
asylums and among idiots, is not a mere degeneration signi-
fying ' irritable' brain tissue or deficient development, but
is a result of such causes as intra-uterine or infantile menin-
gitis. After ischaemia, then, and after acute neuritis, the disks
no doubt present distinctive features during a longer or a
shorter time, according to the degree of effusion or of neuritic

16 Vide Liebreich, 'Atlas,' Tab. xi. figs. 13 and 14.

iv.] OF THE OPTIC NERVE AND RETINA. 69

resistance this is transition atrophy. The swollen disk recedes
gradually, and the reds and greys give place to dirty white,
the margins being either completely blurred, or slowly extri-
cating themselves here and there, as if the disk had been
crushed and its contents squeezed out. Streaks of exudation,
which are often continuous with smudgy parts of the disk,
remain, though not so long, in the course of the retinal vessels.
Little by little the disk clears up ; it whitens and the edges
become more detached, the exudation often remaining in little
grey satellitic dots around it. All haemorrhages shrivel,
whiten, and disappear, and the fine vessels are no longer seen
on the face of the disk, though there is not the same delicate
shrivelling and waning of them against the white background
which we see in chronic neuritis. On the retina the arteries,
which had long been diminished in size, remain small, while
the dark thick tortuous veins decrease slowly. As the face of
the disk clears and whitens, they diminish a great deal, though
they never sink much below the normal standard. We find,
on examining such nerves with the microscope, that the new
but instable connective elements disappear slowly even after
great inflammatory proliferation, until the nerve becomes a
mere fibrous cord, as in primary atrophy. Very commonly
ischemia does not result in complete atrophy; and I have
some reason to hope that neuritis does not always, for under
the microscope I have several times seen advanced neuritis
and great proliferation with the nervous fibres still intact or
almost intact ; but I have always believed that neuritis means
great danger within the head. I have now several little patients
under observation, who, having suffered from meningitis with
ischsemia papillaris, are passing through the peril of atrophy
with good hopes of safe vision. The danger of meningitis
to the sight has, however, been known for a great number of
years. Gralezowski thinks that consecutive atrophy admits of
melioration and cure in perhaps one case out of every three.
But these statistics are of less value, as he has not recognised
the distinction between ischsemia and descending neuritis,
which latter is far more dangerous to vision. Mr. Oglesby has
given a good deal of attention to the final results of atrophy

70 VARIATIONS FROM HEALTH [CHAP.

in their bearing upon vision, and he has recorded 17 some
very interesting cases of atrophy of the second and third
degree, in which some sight was regained after long lapses
of time. Like Galezowski, however, Mr. Oglesby has not
clearly distinguished in the histories of his cases between
consecutive and primary atrophy; nor, again, between the
two kinds of consecutive atrophy that which follows ischse-
mia papillaris, and is probably confined to the disk, and
that which follows descending neuritis, and is a wasting of
the nerve in more or less of its length. When old amaurotic
cases present themselves for treatment, I believe it is often
impossible to tell, by the ophthalmoscope alone, to which
of these classes the atrophy belongs.

I need scarcely say that these modes of atrophy must be
distinguished from

1. Atrophy with (great) excavation or glaucoma. This is
known by tension of the eyeball with ciliary pain, by the
double border of the disk (the choroidal border and the edge
of the cup), by the shadow thrown into the cup, by the
curious incurvation of the vessels, by the atrophy of the
neighbouring choroid, &c. In cerebral atrophy, if the cup
be rather deep, it is never abrupt at the edges.

2. Atrophy following 'pigmentary retinitis/ Here the
mischief is mainly and firstly retinal, and the retinal vessels
are diminished.

3. Atrophy following syphilitic or other irido-choroiditis.
They are attended with widespread retinal mischief, and do
not at all resemble cerebral atrophies.

4. Atrophy following myopia. Is seen only in extreme
cases, and then with posterior staphyloma.

5. Atrophy following albuminuric degeneration. Is dis-
tinguished by the peripapillary and retinal distribution of
the mischief, by the presence of fresh or old haemorrhages,
and of fatty patches; also by presence of albumen in the
urine, &c. This atrophy generally follows, or always follows,
extensive destruction of the retina, but I have seen some early

17 'Lancet/ Aug. 22, 1868. Also 'Royal Ophth. Hosp. Reports,' vol. vi.
pt. iii. 1869.

iv.] OF THE OP TIG NERVE AND RETINA. 71

cases where there was little more than a pseony-red tint around
the disk, and some hyperaomia, and these might mislead even
a wary observer, unless all the symptoms were investigated.

K. Primary Atrophy.

Atrophy which is 'primary' at the disk may nevertheless
be the consequence of neuritis, for neuritis in some intra-
cranial part of the nerve length may reveal itself at the
disk simply as atrophy as atrophy due to a separation of
the distal from the central parts. Atrophy presents two
different aspects to the observer, though I shall not dwell
long on the difference, as it seems to be of little clinical
importance. The one kind is a grey shrinking of the nerve
and its expansion, with a great tendency to cupping; the
other is a dense tendinous white disk with a good deal of
connective tissue growth, and less tendency to cupping.
The former kind involves only the filament and ganglion
layers of the surrounding retina, while the latter invades all the
layers, and is probably always preceded by some degree of
neuritis, acute or chronic. In both cases the finer vessels fade
away, leaving the disk a dead white, and in dense atrophy
the thickening and contraction of the sheath of the central
vessels lessens even these in calibre. Under the micro-
scope we find, after all the more active periods of degener-
ative hypertrophy have passed away, that neither nervous
elements, nor perhaps any fatty and granular remnants of
them, are anywhere to be seen. Even the new connective
elements themselves dissolve and shrink down into a mere
band of fibrous tissue, containing the tracks of degenerated
vessels and a few wrecks of bygone structures, cellular and
other. These changes largely involve the retina also, though
it is surprising how little central vision may be affected in
the earlier stages, or in the not uncommon incomplete forms.
I used to be amazed sometimes to see white and even glisten-
ing optic atrophy in eyes which could read ordinary types
with ease. Such cases are only discovered by the physician,
at any rate in their earlier stages, and sometimes the mischief
seems arrested at these earlier stages. On the other hand,

72 VARIATIONS FROM HEALTH [CHAP.

sight sometimes seems to vanish when the mirror betrays but
little whitening or apparent degeneration. In the former
cases some nerve fibres must survive much longer. Primary
atrophy also may occur in any part of the nerve length from
the quadrigeminal bodies downwards, and so affect vision very
seriously before the disks are actually reached.

Of the diagnosis of atrophy I have said something already
in the section on anaemia. It is often very hard to tell
whether atrophy be or be not present in the early stages.
Mapping the field will help us, for if the deficiency of vision
be uniform, we have probably a state of anemia present, and
anemia only; if, however, any part of the visual field be
wanting, we have to fear that the state is one of commencing
atrophy. In simple atrophy, which is more dangerous to
vision than consecutive atrophy, we have a more evident
dwindling of the vessels. The vessels often begin to shrink
a little from the first, and when they do we have an im-
portant sign of atrophy before us.

Or we may detect a slight cupping, which is a sign
of atrophy, but which may unfortunately also be a physio-
logical peculiarity. Cupping, as an unimportant abnormity,
has been described in the third chapter ; I will only add
here a few remarks on the cupping of atrophy. In the first
place, let me say that it is scarcely possible for the observer to
make much of an atrophic excavation in the inverted image.
In the erect image we see a uniform depression with sloping
sides, not thrusting out the lamina cribrosa, but simply showing
a thinning away of substance from before it, and allowing the
pitting of the lamina to become more visible 18 .

The course of the vessels must now be very minutely
regarded. By slightly varying the lenses, the observer may
satisfy himself of the degree of excavation, and may tell
whether the vessels do or do not bend sharply over the
edge of the basin. If there be an abrupt bend as they
dip, then the case is one of glaucomatous excavation; if

18 In consecutive atrophy the disk may be prominent with the products
of previous cell growth not yet dissolved, or it may have a fictitious prominence
due to the wasting and subsidence of the surrounding belt of retina.

iv.] OF THE OPTIC NERVE AND RETINA. 73

the bend is quite gradual, the excavation is not glaucomatous.
A binocular instrument is useful in these cases, but unfor-
tunately it is only available for the small inverted image.

The causes of simple atrophy are of four kinds. Firstly,
it may be due to any cause, such as a tumour, or a patch
of inflammation in the course of the nerve behind the eye,
which severs the nerve fibres and leaves the separated parts
to wither. Secondly, it may be due to destruction of the
centres of vision making the nerve useless, this being merely
another form of the first cause. Thirdly, and very commonly,
it is a sclerotic process associated or continuous with patches
of sclerosis elsewhere, as in the spinal cord in loco mot or ataxy,
or in the encephalon in several forms of chronic degeneration.
Fourthly, it is often due to deficiency of nutrition, such as
we see in senile degeneration of the arteries, in embolism and
the like. Atrophy due to arterial failure and suggestive of
general senility in. the encephalic arterial system is very
valuable as a symptom, but is often so slight as to be
doubtful, or to be mistaken for the normal grey of age.
When it occurs it may be associated with central softening
and haemorrhage.

In concluding this section I should add that certain
curious discolorations of the disk sometimes precede atrophy.
They may be seen in the inverted image when they are far
advanced, but in the erect image are often to be seen much
earlier. We sometimes see a greenish and sometimes a bluish
tint. The word ' slaty' may express the tint, some slates
being greenish, others rather blue. This may be some stage
of chronic neuritis, a sort of ecchymotic change, or again it
may be sclerosis which gives the same grey look to the optic
nerve that it gives to the pons or to the columns of the cord.
I have certainly seen it sometimes follow a red disk. It is
not uncommon in symptomatic nerve disorders, in encephalic
or spinal disease, and not uncommon again in the amau roses
of lead and other slow poisons. In rare cases we may see
one disk in evident atrophy, while the other is curiously
discoloured. One or two pictures of such disks are shown
in Liebreich's ' Atlas,' Plate xi.

CHAPTER V.

ON THE RELATIONS BETWEEN CERTAIN INTRACRANIAL

DISORDERS AND AFFECTIONS OF THE OPTIC

NERVE AND RETINA.

THE most important question which presents itself to us
in this part of our enquiry is the general question does
degeneration of the optic nerves always mean that there
is some serious lesion in the cerebrospinal cavity?

In dealing with this question I must ask leave to set aside,
as foreign to the main object of my investigation, all those
causes of change in the optic nerve which are confined to
the orbit and face, or which originate at least without
the encephalic cavity. This very interesting class of cases
belongs rather to surgery than to medicine, and has been
well described by many writers, especially by Mr. Salter
in his paper on 'Nervous Affections from Diseases of the
Teeth/ in the Report of Guy's Hospital for the year
1868.

Now, these exceptions being made, and likewise all albu-
minuric, glaucomatous and other merely local changes being
classed apart, what are we to infer from the presence of
papillary ischsemia, optic neuritis, or optic atrophy ? Up to
a quite recent time, I believed that the existence of such
changes pointed almost certainly to cerebrospinal mischief.
Of late, however, my opinion has become less strong, and
I have begun to think that I assumed too close a connection
between optic neuritis and cerebral mischief. In preparing
to write this volume, I have run through a great deal of the

INTRACRANIAL DISORDERS. 75

writing of ophthalmic surgeons, and I have read notes of a
large number of cases of neuritis and of atrophic amaurosis
in which there seemed to be little likelihood of concurrent
cerebral disorder. When an ophthalmic surgeon records cases
of optic neuritis as occurring in persons who present no
symptom of cerebral disorder, and records them side by side
with other cases in which cerebral disorder undoubtedly
existed, showing thereby that he was fully alive to the prob-
ability of the co-existence in both classes of cases, when,
moreover, these persons present themselves time after time
for examination and develope no symptoms beyond those of
the eye, and go through all the local changes of neuritis
followed by atrophy, when we see such cases carefully re-
corded, as they are by Mr. Hulke, for instance, in his
interesting notes published in the ' Royal Ophthalmic Hospital
Reports,' vol. vi. April, 1868, we physicians must, I think,
be prepared to modify our previous exclusive notions, and to
admit that there is no necessary connection between optic
neuritis and cerebral disease on the one hand, as the surgeon,
on the other hand, admits that cerebral disease may exist
without optic neuritis 1 .

At the same time, after making full allowance for the
different conditions under which ophthalmic surgeons and
physicians are practising, remembering also that no patients
come to a physician for eye mischief alone, yet I cannot
but think that uncomplicated optic neuritis is a rare event.
From the very nature of the circumstances, when we have
a case of optic neuritis before us, we are only able to base
our supposition of a sound encephalic condition upon negative
evidence. A small morbid growth or inflammation so placed
as to interfere with the optic nerves or centres might, for a
long time at least, give rise to very few symptoms. I have a
patient under my care at present with well-marked symptoms
of cerebral tumour, who had been afflicted with amaurosis
from atrophy for three years before any cerebral symptoms

1 A similar local neuritis may account for the occasional appearance of
palsy of one orbital nerve independently of syphilis, locomotor ataxy, &c.

76 OPHTHALMOSCOPE IN [CHAP.

became manifest. Again, as in Case 77, a patient may
have suffered from cerebral symptoms in time past, but
which have wholly or partially subsided : he may then
begin to suffer from loss of sight, and seek the assistance of
an ophthalmic surgeon, and the surgeon may not light upon
the old history. In Case 78, the history of old cerebral
symptoms had almost escaped me, who am constantly on
the look-out for such things, and the woman only recalled
them by an effort of memory. The cerebral symptoms of
Case 77 might easily have escaped notice, as the only symptom
the woman complained of was 'sick headache.' Here we
are met by the grave difficulty which besets all new clinical
investigations, we have no long list of autopsies to check or
inform our judgments. Cerebral diseases are often so long
in their course, and pass under so many medical men in
turn, that the uncertainty of obtaining post-mortem exami-
nations, which is great in all cases, is greater than ever
in that class with which we are now dealing.

It is sufficient, at present, to say that the occurrence of
papillary ischsemia or of optic neuritis in any person ought
to awaken the gravest suspicion of cerebral disorder, and
that the occurrence of simple atrophy should suggest great
watchfulness; that the precise degree of meaning to be
attached by the physician to optic neuritis cannot, however,
be determined until a certain number of cases of optic
neuritis, without apparent cerebral changes, have been traced
to the post-mortem table. Meanwhile, the physician will
not often be called upon to determine the meaning of
neuritis alone, it will come before him in cases where other
symptoms will also be present to assist his diagnosis,
and we must follow up the uncomplicated cases at eye
hospitals.

I shall now discuss the effects of various forms of en-
cephalic disease upon the optic disk and retina. I propose
to take these various forms separately, and to ascertain what
changes in the optic nerves are known to accompany each
of them ; we shall then be in a position to try to draw some
general conclusion concerning the way in which encephalic

v.] INTRACRANIAL DISORDERS. 77

changes are propagated to the optic nerves, and concerning
the importance of the messages which these nerves convey
to us. I need only look to convenience in making a classifi-
cation of encephalic disorders; the following arrangement
is, I think, defensible from that point of view, and that
only :

I. Epilepsy, page 77.
II. Chorea, page 83.

III. Mania, page 83.

IV. Dementia, page 85.
V. Meningitis, page 85.

A. Tubercular. _Z?. In Pyaemia and Fevers.
C. Syphilitic and Rheumatic. D. Of Drunkards.
E. Traumatic.

VI. Concussion and Fracture, page 109.
VII. Hydrocephalus, page 112.
VIII. Tumours and Periostitis chronica, page 114.

IX. Atheroma, Softening, and Haemorrhage, page 178.
X. Cerebritis, Abscess, and Sclerosis, page 186.
XI. General Paralysis, page 193.

I take a disease first which is very interesting from its
almost negative results as regards the eye, so that, before
seeing what sort of diseases do permanently affect the eye,
we may see that some very serious diseases have no such
consequence.

I. EPILEPSY

is a name which we are not to apply to convulsive symptoms
generally, but to a certain group of convulsions which tend
to periodical recurrence, affect both sides of the body, are
closely associated with unconsciousness, and do not depend
upon obvious disease of the encephalon. So long as we
are to use the word ' epilepsy ' at all, let us use it in this
rigidly defined sense, as laid down by Dr. Russell Rey-
nolds ; in no other sense can epilepsy be appropriately
said to name a disease, for it can have no other constant

78 OPHTHALMOSCOPE IN [CHAP.

application. It is generally held, at present, that the con-
vulsions in which epilepsy almost wholly consists, and which
form a part of many other diseases, such as encephalic tumour,
or meningitis, depend upon partial anaemia of the hemispheres
and central ganglia. Such convulsions occur in animals
which are bled to death. In epilepsy they are supposed
to depend mediately upon a spasmodic contraction of an
arterial region, such, for instance, as the region of the middle
cerebral artery 2 . This hypothesis seems to be supported
by many observations, but as yet is very far from proof.
Among the analogies which favour it may be named the
sudden losses of equilibrium which seem to occur in other
arterial regions, as in the anterior lobes and olfactory lobes
of the encephalon, and as in the retina. Diarrhoea, diuresis,
and many other temporary disturbances of function are often
traced with much likelihood to the influence of nerves upon
vascular supply. We have also arrived at similar conclusions,
experimentally, from researches made into the influence of
nerves upon the vascularity and so upon the function of
the salivary glands, upon the nutrition of the eyeball, and so
on. In epilepsy, the sudden pallor of the face is commonly
quoted as an evidence of cerebral pallor ; little weight, how-
ever, can be attached to this observation. In the first place,
it is not constant; and secondly, it does not appear to be
generally noticed that the arterioles of the surface of the
head are under the same nervous governance as those of
the brain. The pallor of the face is more likely to be due
to the general nervous shock, and is akin to the pallor
which accompanies other nervous disturbances, which are
set up either from within or from without by such in-
fluences as terror and the like 3 . I am myself disposed to

2 Vide Dr. Hughlings Jackson, passim.

3 A great number of epileptics complain of disordered vision before or after
their fits, but this is often the effect also of general nervous shock ; it is
transient, and it coincides with disorders of other functions governed by the
brain, such as perturbed hearing and speech, vertigo, and the like. I have
never been able to trace it to any indubitable change in the disks or retinas,
though I have over and over again examined the eyes under these circum-
stances. Vide cases in the Appendix.

v.] INTRACRANIAL DISORDERS. 79

attach great weight to the observations and reasonings
which have attributed epilepsy to disturbances near the
fourth ventricle. This is not the place to enter upon so
large and so interesting an enquiry, but I will only refer
to the well-known occurrence of bilateral convulsions exactly
like epilepsy, which follow an injury below the floor of the
fourth ventricle. This experiment has been recently repeated
and verified by Dr. Nothnagel [ Virchow, ' Archiv.' vol. xliv.
1868], who determines with great minuteness the precise spot
whence these convulsions are determined. Whether the
convulsions of epilepsy be due to disordered blood-supply
in the great central ganglia, or to some disturbance, vas-
cular or other, at a ' cramp point ' near the fourth ventricle,
is therefore a very interesting subject for enquiry. The little
evidence which we receive from the ophthalmoscope tends
rather to favour the otherwise likely supposition that epi-
lepsy is the common result of more than one cause that
not ' symptomatic convulsions ' only, but ' genuine ' bilateral
tongue-biting fits are either the way in which the whole
encephalon manifests an overthrow, which, again, may be
variously brought about, or may be in other cases the con-
sequence of a local disturbance, say, in the pons, or upper
medulla oblongata. For instance, my own experience of
post mortems in epilepsy would lead me to think that
venous congestion may have the same effect upon cerebral
function as ansemia, and the ophthalmoscope points to a
like conclusion, for I have noticed congestive appearances
in the optic disks more than once in persons suffering from
epileptic fits. The indications of the ophthalmoscope divide
themselves naturally into two parts; into the appearances
seen during the attacks, and those seen during the intervals
between the attacks. The difficulty of examining a patient
during an epileptic fit is considerable : sometimes, however,
it may be overcome with a little dexterity and patience.
I have managed to see the disks distinctly during the
convulsions in many cases of epilepsy, and of six cases I
have careful descriptions in writing. [Vide App. Nos. 2, 3,
5, 6, 8, 17.] In three of these I found an anemic condition

80 OPHTHALMOSCOPE IN [CHAP.

of the disks, and in three a hypersemic, or congested con-
dition; a curious opposition of experiences. Of the anaemic
cases two were seen in the Leeds Infirmary, and one in the
Wakefield Asylum : those seen in the infirmary were both
out-patients, who were daemonized during- the hour of attend-
ance. In these two I saw of course the character of the
convulsions, and knew the past history of each case. In both,
the disks were very white and small, though in both the
arteries could be distinguished from the veins ; the whiteness
trespassed to a small extent upon the surrounding belt of
retina. I examined the eyes of both the patients before and
after the day of the convulsions, and noted nothing, or but
little abnormal. The third case, which I saw at the Wake-
field Asylum, is the young man C. W , marked No. 13

in my list of cases of epilepsy with insanity, published in
the 'Transactions of the Medical and Chirurgical Society'
for 1868, and republished in the Appendix.

On one of my visits I had examined his eyes, and noted
the disks as healthy, the vessels being large and full. On
a subsequent visit he was brought to me in haste, by
Dr. Crichton Browne, as he had just passed through a
violent epileptic paroxysm, and still had visual and other
hallucinations. I found the 'vessels very small, few and
fine,' in the right eye ; in the left, ' vessels smaller than
before, but artery and vein distinctly visible.' Dr. Hughlings
Jackson has reported more than one case in which he ex-
amined the optic disks during epileptic states, and found
them to be anaemic ; one very interesting case was published
by him in the ' Medical Times and Gazette,' for Oct. 3, 1863,
and is reprinted in the Appendix, No. 2.

Mr. Carter once told me that he had examined the eyes of
a patient who had just passed through an epileptic paroxysm.
He saw the optic disks as soon as convulsion ceased, and
found that the nerve tissue was almost as white as in atrophy.
The state of the retinal vessels he had forgotten. The num-
ber of observations of the optic nerves at or about the times
of convulsion in epilepsy is not great, the occasions of them
are rare, and the difficulties considerable ; but it seems so far

v.] INTRACRANIAL DISORDERS. 81

that there is a certain agreement in the results of those
which are recorded, and that the evidence in favour of a very
decided anaemia of the optic disks being a frequent, if not a
constant, phenomenon during the convulsions of epilepsy, is
quite worthy of attention. If it be true, it is a very remark-
able and important discovery. , I am disposed to think that the
optic anaemia may persist for some hours, or even perhaps days,
after the convulsion has passed away. In some of my own
cases, in the case published by Dr. Jackson, and in Mr. Car-
ter's case, the whiteness was noted after the convulsions had
passed away. I may refer also to Case No. 6 in the Appen-
dix, as showing how long some anaemia of the disks may sur-
vive the convulsions. This case is not included in the half-dozen
to which I have already made reference. I shall return to
this question when I discuss the state of the disks and retinas
between the paroxysms. Before leaving the present subject,
however, I must still point out that anaemia of the optic
disks has not been by any means a constant condition in my
observations during epileptic convulsions. I have said that
in three out of six cases I found decided hyperaemia with more
or less exudation in the disks. Case No. 5 is one of these, and
I publish it because we proved, by post-mortem examination,
that there was no ' coarse disease ' in the brain. All three were,
however, cases of prolonged convulsion alternating with times
of stupor of the status epilepticus as it has been called. In
these three cases I found the disks greyish red, and perhaps
a little swollen ; the borders were somewhat concealed, and
the retinal vessels were very dark and full. In the case which
we examined after death there was great venous congestion
of the encephalon ; and I have no doubt that the state of the
disks was one of slight ischaemia, and was due to congestion
in the cavernous sinus. The state of the disks varied little
or not at all during the change from convulsion to stupor, in
each case ; nor did the retinal vessels vary in the least with
the convulsions of the iris. These observations support my
belief that convulsions may accompany venous hyperaemia of
the brain as well as anaemia, both conditions being sup-
pressions of arterial supply ; at any rate, they must not

82 OPHTHALMOSCOPE IN [CHAP.

be lost sight of in any comprehensive discussion of the
subject.

During the intervals it may be said, in a general sense,
that the optic disks and retinas regain their equilibrium and
appear normal. There is usually no appearance during the
intervals of epilepsy proper which would justify an ordinary
or a casual observer in pronouncing that the back of the eye
is otherwise than healthy ; nor is there any permanent dis-
turbance of sight in those cases which are attended with
periodic amblyopia. After a large experience of epileptic
eyes, however, and after careful comparison of them as a class
with the average state of the eyes in healthy persons, I think
I am justified in expressing an opinion that in epileptics who
suffer from violent fits, or from frequent fits, there is during
the times of repose a higher degree of vascularity in the optic
disks and retinas than is quite normal. There is often a pro-
nounced redness in the disks of such patients, which does not
obscure their edges, for it is attended with no exudation, but
which makes the white centres shine out with unusual bright-
ness. The retinal vessels in such cases also are large, both
the arteries and the veins being full, and the minuter branches
of both can be traced more easily in their course in the
retina.

I have been accustomed for some time to point this out to
my colleagues and pupils, and have often said that I thought
I could pick out an epileptic, by the appearance of his disks
and retinas, from a row of healthy persons. I have recently
noticed that M. Bouchut expresses the same opinion. I think
M. Bouchut is often rather hasty in pronouncing upon de-
grees of vascularity in disks and retinas, but in the present
case I am prepared to give him a general support. If it be
finally agreed that such appearances are common in the eyes
of epileptics during the intervals of health, we shall have dis-
covered a fact which is of high interest, when taken together
with the changes noted during the attacks ; for it may sig-
nify either a general vascular relaxation, or a venous conges-
tion secondary to frequent arterial disturbances.

Optic neuritis, ischsemia papillae, and atrophy seem to be

v.] INTRACRANIAL DISORDERS. 83

as rare in epilepsy as they are common in symptomatic con-
vulsions.

II. CHOREA.

The eyes of patients suffering from chorea have been exa-
mined with the mirror in a large number of cases by Dr.
Hughlings Jackson and myself, and no doubt by many other
investigators.

It may be looked upon as established that no change either
in the vascularity or in the nervous tissue of the disk and
retina is to be found in simple chorea. I have not thought
it necessary to publish any cases in support of this statement,
though I do publish one case in exception which was reported
by Dr. Hughlings Jackson (Appendix, No. 19); it is interest-
ing to notice that the signs resembled those sometimes seen
in cases of undoubted embolism.

III. MANIA.

Mania which depends upon such marked anatomical changes
as meningitis and the like is not here to be considered, but
only that form of acute insanity in which the pia mater and
hemispheres are found to be highly hypersemic. As some
forms of acute melancholia attended with great variety of
action nearly approach mania both in symptoms and in the
post-mortem appearances, the subject of this paragraph may
be stated as acute insanity with cerebral hypersemia. In that
form of melancholia which it is better to call 'profound'
rather than ' acute,' and which depends less upon hypersemia
than upon serous exudation, and perhaps upon anaemia, the
fundus seems to be either unaffected, as I have shown in
a contribution to the ' Medico-Chirurgical Transactions' of
1868, reprinted in the Appendix; or, if affected, is but
simply anaemic, like the rest of the tissues- in the body. In
one or two cases of recent and profound melancholia I have
notes of reddish disks, but I cannot attach much importance
to them. In acute insanity, however, I have shown to some
extent in the same paper, and have since had occasion to

G 2

84 OPHTHALMOSCOPE IN [CHAP.

notice, that during a short but variable time after the
paroxysm, the back of the eye, when examined with the
mirror, presents a vascular suffusion or pinkness a pinkness
so great, after severe paroxysms, as to obscure the disks. A
like suffusion is sometimes to be seen also in the conjunctiva.
No exudation or permanent mischief is seen unless the mania
be complicated with some more definite structural change in
the encephalon. The difficulty of seeing the disk is at least
as great in maniacal paroxysms as in epilepsy, generally
perhaps much greater. It is not often pleasant to try to
examine the optic disks of a raving maniac, and I have only
once seen the disks in such a case. In that one instance
I found the disks white : the patient, B. W. S., age 23, in
the Wakefield Asylum [Schedule II., No. 31, Appendix],
was suffering from acute mania, and by good fortune we
secured an examination during a paroxysm. The right
fundus was anaemic and the disk rather white, looking like
atrophy : the left eye was like the right, except that there
seemed to be some normal vascularity at one point of the
margin of the disk. I cannot attach much weight to this
single observation, but I may allude to it as suggesting that
mania, like epilepsy, may be due to vascular spasm.

My observations of the hypersemia of the eye after the
paroxysms correspond closely with the state of hypersemia of
the brain noticed after death in such cases. Should my state-
ments be verified hereafter, either by myself or by other more
competent observers, the state of the disks and retinal vessels
in mania will be a remarkable and valuable proof of the close
dependence of their circulation upon that of the brain, and
will add much to our confidence in reasoning from the one to
the other. As a means of diagnosis it will be seen that the
use of the eye mirror in the investigation of insanity is chiefly
for the distinction of ' organic ' from ' functional ' disease. As
in epilepsy, when, the mania is symptomatic of ' coarse dis-
ease/ we find permanent changes in the disks due either to
obstruction to the intracranial circulation, that is, to ischse-
mia, followed perhaps by atrophy, or due to neuritis, or
again, to simple progressive atrophy. No such changes

v.] INTRACRANIAL DISORDERS. 85

occur in ' functional mania/ [Vide Cases of Mania in
Appendix.]

IV. DEMENTIA.

In dementia the changes seen by the ophthalmoscope are
numerous. I found marked changes in and about the optic
disks in twenty- three cases out of thirty-eight : six more being
recorded as doubtful. [Vide Appendix.]

None of these cases were epileptics, but the class of dementia
is a very heterogeneous one, and includes worn-out lunatics
of all sorts. A large number of those whom I examined
were known to have organic disease of the encephalon, and
this accounts for the high average of optic disorders among
them. We shall gain nothing, I think, by associating optic
changes with dementia as such ; so far as these are the conse-
quences of organic disease, we shall discuss them in other
paragraphs with more perspicuity.

V. MENINGITIS.
A. Tubercular Meningitis ; or Granular Basilarmeningitis.

In some forms of encephalic disorder as in chorea, for
instance the ophthalmoscope gives us little or no help ; in
other forms as, for example, in general paralysis or ence-
phalic tumour its discoveries have important pathological
meanings ; in other forms, again, the ophthalmoscope may
give us most valuable help in diagnosis, and this is the case
in some kinds of meningitis. During the last few years I
have given a great deal of time and care to the investigation
of the states of the eye in meningitis, and I hope to be able
to show that my pains have not been thrown away. I shall
first speak of that form of meningitis which is called ' tuber-
cular,' for it is upon this form that I have the most important
statements to make.

I began to use the ophthalmoscope in meningitis as a help
to the general study of that most important disease. I had
long been convinced that tubercular meningitis, as a disease
of children, is more common and less uniformly fatal than is

86 OPHTHALMOSCOPE IN [CHAP.

generally supposed. In its milder forms, however, it is very
difficult of diagnosis ; and as before the discovery of the
stethoscope the diseases called phthisis were supposed to be
almost invariably fatal, because the cases which were so well
marked as not to admit of doubt were fatal, while the nature
of milder cases which admitted of recovery were open to ques-
tion, so it is now with tubercular meningitis. Those cases
which present no difficulty of diagnosis are the extreme forms
which kill, while those which admit of recovery are not to be
diagnosed with certainty. Can the ophthalmoscope help us
in this difficulty, and may we hope to see it play in tuber-
cular meningitis the part which is played by the stethoscope
in tubercular pneumonia ? The help we get from the stetho-
scope is this : A patient who has been languid for some
months, who has lost weight, whose appetite and digestion
have been uncertain, and who may have spit a little blood, or
have coughed a little, comes for our opinion. We then exa-
mine the chest with the stethoscope. We may find nothing,
not infrequently we do find nothing, and in such cases we
cannot go beyond a guess in our diagnosis, although the sub-
sequent course of events may prove that the lungs were actu-
ally diseased. Or, again, the stethoscope may put us in pos-
session of evidence which establishes the diagnosis, and enables
us to ascertain that the lungs are diseased a certainty which
is not to be shaken by any subsequent course of events, even
if they terminate in recovery.

Now I think I am in a position to say that we get some
such help as this from the eye mirror in tubercular menin-
gitis; that the mirror enables us to learn something more
concerning the clinical history of meningitis than we know
already, and that this additional knowledge will bring about
some change in our views and opinions concerning the fre-
quency and the curability of this formidable disease.

I have already described the modes of origin of ischsemia
papillarum, of neuro-retinitis, and of atrophy. I need not
again go over this ground to show that in meningitis the
exudation at the base of the brain may press upon, or the
inflammation may involve, the cavernous sinus, and slacken

v.] INTRACRANIAL DISORDERS. 87

the ebb of the blood, in which cases we have ischaemia only.
Or the inflammation may creep down the nerve and cause
neuritis optici, or may creep mainly along the sheath and
cause perineuritis. Or, again, it may both interfere with the
sinus, and so with the ophthalmic vein, and may likewise
creep down the nerve ; in such a case we should have ischaemia
followed by neuritis. Finally, these states may be followed,
and often, though by no means always, are followed, by
atrophy ; but it is not probable that simple severance of the
continuity of the nerves often occurs in meningitis so as to
cause a primary atrophy of the disks an atrophy, that is,
without forerunning congestion or inflammation. The anterior
subarachnoid space, with the Sylvian fissure, is a district which,
as we know, is especially one of the districts of tubercular
meningitis, and the chiasma seldom escapes. In their back-
ward course, from the chiasma up to the tubercula quadri-
gemina, we know also that the tracts are closely invested by
the highly vascular pia mater, and that they are in great
measure dependent upon it for their nutrition. Inflammation
of the membranes upon the tracts, chiasma, or optic nerves,
therefore, not only creeps up -to the eye and presents its cha-
racteristic cell proliferation, but it also cuts off nutriment from
the nervules. This compound mode of change I have several
times verified with the microscope, and have seen the gross
connective tissue of neuritis enclosing, not crushed nerve-fila-
ments, but empty or half-empty spaces from which the fila-
ments were withering or had withered away. This condition
is best seen in some more chronic cases.

It is, I believe, the opinion of most if not all physicians,
that tubercular meningitis is invariably fatal. I see, for
instance, that Dr. Wilks, in his recent lectures on Diseases
of the Nervous System, repeats and adopts this opinion.
Many medical men, however, while upholding this belief, will
nevertheless say that in the course of their practice they have
seen one or two cases much resembling tubercular meningitis
which recovered. The mere fact of the recovery makes them
doubt theiu own diagnosis, and makes them suppose that the
case which, had it been fatal, would unhesitatingly have been

88 OPHTHALMOSCOPE IN [CHAP.

called tubercular meningitis, cannot have been meningitis
because recovery took place. Indeed, it is well known that
the diagnosis of tubercular meningitis, even in well-marked
cases, may often be very doubtful. Children not infrequently
present symptoms much like those of meningitis, but which
turn out to be significant of mere disturbances, or of cere-
bral diseases of other forms. And as this is true of cases
which present decided symptoms, so much more is it true
of cases presenting indefinite symptoms. The fever, the
headache, the scream, the vomiting, the perturbed sleep,
the strabismus, and other decided symptoms, followed by
death, point undoubtedly to tubercular meningitis, and to an
extreme case. But does meningitis occur only in extreme
forms ? or may it occur in milder forms which end in reco-
very? In milder forms we might have occasional but not
urgent vomiting, some pain in the head but not violent
pain, some startings in the sleep, or even slight passing
convulsive attacks ; but all these taken together may
well be attributed to some disorder far less terrible than
tubercular meningitis. Hence, as I have said, it appears
that, at present, meningitis can only be diagnosed with
certainty, or, indeed, with any great degree of probability,
in its extreme forms, which extreme forms are of course
largely fatal.

The important question for us to decide is, whether
we have any means of detecting with certainty the presence
of meningitis in those slighter cases where we can now only
guess at it, or can scarcely even guess ; and in which cases
we need not expect to find a large percentage of mortality.
It is here, I think, that the ophthalmoscope comes to our
assistance, and gives us the same kind of help in detecting
incipient or slight degrees of tubercular meningitis that the
stethoscope gives us in detecting those incipient or slight
degrees of ulcerative change in the lungs, which without it
are beyond certain diagnosis. When a patient is seized with
vomiting, headache, convulsions, and other symptoms of much
meningitis, and when at the same time, on examination with
the ophthalmoscope, I find congestion of the optic disk and

v.] INTRACRANIAL DISORDERS. 89

retinal vessels, which is frequently the case, then I have
no hesitation in saying that the patient is suffering from
meningitis at the base of the brain, and the autopsy proves
the diagnosis to be correct. Suppose, however, that a child
is liable to occasional vomiting of a ' purposeless ' kind, and
attended with but little nausea ; suppose him to be liable to
an evening fever, and to be rather restless, or sometimes
very restless at nights ; suppose, moreover, that he complains
of pain in the head from time to time of a kind which drives
him for a few hours only from his companions and his games,
or perhaps for a day or two ; suppose, again, that his temper
changes, and from being a good child he becomes irritable or
even positively mischievous, while at the same time his me-
mory does not develop, and he is quite unable to fix his atten-
tion upon his school work ; suppose, farther, that he suffers
from spasmodic movements during his sleep, or even from full
convulsions, and that the child nevertheless recovers from this
state, and returns either to full health, or to health of body
with more or less injured mental faculties, should we call
such a case meningitis ? Now, I have had many such cases
under my care, and I have records of many in which the
ophthalmoscopic appearances were noted throughout, and in
which I found those same signs in very well marked degrees,
which I have also described as occurring in undoubted cases
of meningitis, proved by autopsy. Is it not probable that in
these cases we have also meningitis a meningitis less severe
than that which proves fatal, but meningitis nevertheless?
The main difficulty I have to contend with in supporting my
view of these cases is, that by the very nature of them I am
shut out from any appeal to the post-mortem table. It may
one day happen that some patient of mine, who has passed
through these states of ill-health, may die from other causes,
and give me the opportunity of verifying or disproving
my hypothesis ; but as yet no such opportunity has presented
itself 4 .

4 These remarks were first published in the 'Lancet' for May i, 1869. In
the same paper is described a case of supposed ' strumous meningitis ' ending in
recovery. The case was under Dr. Radcliffe's care. ' The right optic disk,'

90 OPHTHALMOSCOPE IN [CHAP.

I will relate one case, however, which fulfils these conditions
to some extent a case in which I diagnosed meningitis in a
first attack, and the child recovered, but died from a subse-
quent attack.

Master O , aged six years, was under the care of Mr.

Mann, of Leeds, for obscure head symptoms, suggestive of
meningitis. At the same time (1868) I was seeing another

boy, Master R , also under Mr. Mann's care, for similar

symptoms, A few days afterwards I was requested to see

Master O likewise, so that I followed the two cases

together with Mr. Mann throughout their course. Both
boys complained of fitful headache ; intolerance of light ;
occasional purposeless vomiting, sometimes severe ; much
restlessness and starting, and slight occasional attacks of
a more convulsive character. Now in both these boys
I found with the mirror the condition I have described
as ischsemia papillae, and I accordingly diagnosed menin-
gitis in both. Both the boys recovered in a few weeks,
and I saw them on several occasions subsequently in my
own house, where I also made repeated examinations of
the eyes. The ischsemia slowly subsided, leaving a whitish

look about the disks, which threatened in Master E, to

become actual atrophy ; but the danger subsided, and the
sight remained good so long as I had him under my notice.
His recovery continues, though his mother stated when I
last saw him that he still suffered from some mental inca-
pacity, and a little irritability of temper. In the case of

Master O , the ischsemia of the disks likewise slowly

subsided. He walked several times to my house with his
mother, a distance of at least a mile, and he joined in the
sports of his fellow-boys and girls. One day about six
months later he came into the house complaining of his
head, and the old symptoms of meningitis returned. I
again saw him with Mr. Mann, and discovered neuro-
retinitis. In this attack he died, and we obtained a
post-mortem examination. We found meningitis, and the

it is said, ' was thought to be ill-defined.' Exactly what I should expect ; but
what is the precise meaning of the expression 'thought to be ?'

v.] INTRACRANIAL DISORDERS. 91

mischief was apparently of two dates. There was a layer of
dense stringy lymph about the chiasma, matting it tightly
down, and the membranes in the neighbourhood were con-
densed, opaque, and adherent. Smeared all over those parts
again were fresh layers of lymph ; and there were marks of
recent inflammation in the Sylvian fissure, and all along the
base down to the medulla. The central parts were softened,
and the ventricles full of fluid. I found descending neuritis
in the optic nerves, and fatty degeneration in the tracts and
tubercula quadrigemina. I can scarcely resist the conclusion
that both these boys suffered from tubercular meningitis,
limited in the first instance to a small part of the base of the
brain, and that from this they both recovered under the treat-
ment of cod-liver oil and iodide of iron, which we prescribed ;

but that the recovery of the boy O was only temporary,

and was followed by relapse and death, the autopsy proving
that the second attack, at least, was undoubtedly meningitis.

Mr. Mann tells me that another child of the O family

has since died of meningitis. R is still living. For a

few additional cases the reader is referred to Nos. 2038 in
in the Appendix, some of them being taken from the records
of other physicians.

I could bring forward at least a dozen more cases, fully
noted, in which I suspect that meningitis has existed or now
exists in a mild form, my suspicion being founded upon
the symptoms and supported by the ophthalmic indications.
To relate them, however, would not add anything of import-
ance to that which I have already written, and would take up
much time and space. I must make a reference, however, to
the appearances I have found in the eyes of idiots. I have
found that a certain proportion of the idiots whose eyes I have
examined of idiots, that is, who are not congenitally idiotic,
but with an idiocy due to disease present those changes, or
their results, in the optic disks which I commonly find after
meningitis ; while, as I have said, symptoms of mental de-
terioration or arrest formed a prominent feature in the after-
history of several of the cases which I examined during the
supposed acute stages. May not many of the idiots in our

92 OPHTHALMOSCOPE IN [CHAP.

asylums be the victims of a long-past meningitis, which has
left permanent injury behind it in the brain, but which
has not destroyed life? In the Appendix will be found
the ophthalmic condition of a few idiots vide table; and
Talbot (No. 4) and Milner (No. 8) are good examples of the'
kind of evidence I mean.

I shall now notice two objections which seem to withstand
the hypothesis I have proposed. The first is, that until the
ophthalmoscope has been used more extensively, and its indi-
cations checked by a much greater number of autopsies than
at present, we cannot say with certainty what inferences may
be drawn from the neuritic or ischaemic states of the disks.
It is as yet very uncertain whether optic neuritis always
means cerebrospinal disease of greater or less extent, or whether
it may occur as a local change alone. States of ischsemia,
again, may hereafter be found to accompany states of dis-
turbed cerebral circulation of encephalic congestions, for ex-
ample which might give rise also to the cerebral symptoms
I have described, and again subside, leaving not a trace be-
hind. This brings me to the second and very serious objec-
tion : That thickenings and adhesions of the meninges at the
base of the brain are rarely recorded as old lesions in post-
mortem descriptions. Dr. Long Fox seems to say in his paper
in the fourth volume of ' St. George's Hospital Reports/ that
such changes are more frequent than is usually supposed.
I give one of Dr. Fox's cases in the Appendix (No. 38). It
may be that our attention has not been directed to this point,
and that such changes may be found more frequently if looked
for more carefully ; or it may be, that the membranes clear
up after a long interval of time ; or, again, the new forma-
tions may in time shrink into filmy or thready extensions
which scarcely attract notice. Pathologists have not yet
looked carefully for evidences of old meningitis ; but now that
I have put the question distinctly forward, I hope we shall
soon have that number of able observers at work which only
can settle a point of much difficulty.

I have, however, the pleasure of quoting the following
opinion of Dr. Crichton Browne, whose vast opportunities of

v.] INTRACRANIAL DISORDERS. 93

observation at Wakefield, and whose ability and skill in the
use of them, need not my poor testimony, but give great
value to his statements. I may say that I made no mention
whatever to Dr. Browne of my views on the matter, but
simply put to him the three short questions which are given,
with his replies in full.

i. Whether you think idiocy is often to be traced to
tubercular meningitis of past years ?

' I have seen a few cases of idiocy which were distinctly
referable to tubercular meningitis in early years, and a con-
siderable number of cases in which I suspected a similar cau-
sation, but could obtain no satisfactory proof of it. When
tubercular meningitis is so severe and well marked as to be
diagnosed, it generally ends fatally. It is only when it is so
limited, subacute, or masked as to escape recognition, that it
is likely to pass into permanent forms of mental derangement
or impairment, and then its previous existence can only be
inferred. I am quite persuaded in my own mind that partial
and subacute attacks of tubercular meningitis in infancy and
childhood are much more frequent than is ordinarily sus-
pected, and are sometimes responsible for cerebral abnormali-
ties which the anatomists are in the habit of attributing to
synostosis et hoc genus omne. I am satisfied that they consti-
tute the transition stage through which precocious children
pass into dulness or imbecility of intellect. A little prodigy
of wit and learning loses health and weight, complains of
vague feelings of sickness, giddiness, or drowsiness, and suffers
from night terrors, paroxysms of rage, or hallucinations. His
stomach or bowels are said to be deranged. He emerges from
this trifling illness bereft of his superior powers, stupid, in-
educable, lethargic, or perhaps a partial idiot. Tubercular
meningitis has been quietly and covertly at work undermining
his brain and sapping his faculties, while no one dreamt of
its presence. I have somewhere published a case of moral
insanity (idiocy of the moral sense and hypertrophy of the
animal propensities) which was distinctly traceable to an at-
tack of tubercular meningitis ; and I have met with many

94 OPHTHALMOSCOPE IN [CHAP.

cases of perversion of character and liability to insanity which
could be followed up to the same source. I have no hesita-
tion, then, in classing tubercular meningitis as one of the
causes of idiocy, although I would not certainly give it the
highest, nor perhaps even a middle place, amongst these,
supposing them to be arranged in their order of frequency.
The causes of idiocy are very numerous and various, and
I am not prepared as yet to marshal them in their proper
order/

2. Whether any of the cases of idiocy which I (the author)
examined with the ophthalmoscope were likely to be such
cases ?

' Of the idiots whom you examined here, it seems to me
highly probable that Talbot (No. 4) and Milner (No. 8) may
have to date their idiocy from attacks of tubercular menin-
gitis. 5

3. Did you ever find traces of old meningitis at the base
in cases of idiocy ?

' My own experience in the morbid anatomy of idiocy is
but limited, but I am aware that the appearances to which
you refer bands, adhesions, &c., as also thickenings of the
arachnoid, and miliary tubercles of the pia mater have been
found in autopsies on idiots. I examined the body of an
idiotic boy in the Warwick Asylum some years ago, and found
great thickening of the arachnoid, adhesions between the
hemispheres and anterior and middle lobes (at fissure of Syl-
vius), with fibrous bands at the base, thickening of the velum
interpositum, and remarkable enlargement of the pituitary
body. These changes must surely have been due to menin-
gitis, and to this I set them down at the time. I had no
history, however, to verify my impression. In another idio-
tic lad, whom I also examined in the Warwick Asylum, and
whose case I published in the * Edinburgh Medical Journal '
for March, 1865, I noted firm adhesion of the dura mater to
the skull, especially along the median line, and great thicken-
ing of it posteriorly, thickening of the arachnoid, pallor of the
grey matter, and a glistening appearance and unnaturally
firm consistence, entire absence of the septum lucidum, and

v.] INTRACRANIAL DISORDERS. 95

congestion and redness of the floor of the fourth ventricle;
weight of brain, thirty-five ounces and a half.'

These notes of Dr. Browne's, forwarded to me in his entire
ignorance of the object of my enquiries, are very interesting
and important. The medical officers of any asylum which
receives idiots might make very useful observations on this
subject.

The final question is, How constant are the evidences of
the ophthalmoscope in undoubted cases of tuberculous menin-
gitis ? My opportunities of examination in such cases are not
frequent ; and this question could be answered far better by
physicians of such institutions as the Children's Hospital in
Great Ormond Street. In addition to the cases which have
occurred in my own practice, however, some of the medical
men in this district have also been so kind as to place cases of
tubercular meningitis at my disposal for examination. I find
that ophthalmoscopic examinations seldom annoy the child,
except during a paroxysm of headache ; and they rather please
the parents, who think we are looking into the brain. I have
examined the eyes in about thirty-eight cases of tubercular
meningitis of undoubted characters, which were watched
through their course, and ended in death. I do not include
the indefinite number of cases which I have seen once or twice
at the hospital or at the dispensary, and have not followed up.
In twenty-nine of these cases I found ophthalmic changes ;
and for the most part I found them on the first examination.
The changes were, most commonly, marked degrees of hyper-
semia of the retinal vessels, which become clouded, swollen,
dark, and tortuous 5 . These changes were often traced up to
the full development of ischemia, which appeared next in fre-
quency. Neuro-retinitis I found in about twenty-five per cent.,
as it occurred distinctly in six cases. In five of the cases I

5 A curious change is recorded by Betz (' Memorabilien,' 7, referred to in
Virchow's ' Jahresbericht ' for 1869, vol. ii. p. 477). There was intense injec-
tion of the lower half of the eyeball, which appeared thirty-six hours before
death. At the autopsy, a clot, 3'" long and '" thick, was found in the right
ophthalmic artery before its entry into the foramen opticum.

96 OPHTHALMOSCOPE IN [CHAP.

was present at the autopsy, and found the usual mischief at
the base of the brain, in the Sylvian fissures, around the ven-
tricles, and so on. It is somewhat remarkable that I should
have met with so few exceptions to the rule of concurrence of
the eye-symptoms with the encephalic mischief; but my num-
bers are far too small for any dogmatism. On one occasion,
when I was talking 1 the matter over with Mr. Carter, he said
that he had a case of tubercular meningitis then under his
care at Stroud, in which no eye-symptoms were present. He
promised to examine the child's eyes again and again till
death, and to secure a post-mortem if possible. He was kind
enough to do so, and to place the case at my disposal. (Vide
Case 30 in the Appendix.) There was no mischief at all
about the anterior part of the base of the brain ; but there was
mischief, small in quantity and slight in degree, about the
cerebellar pia mater, especially between its hemispheres. The
optic nerve was not congested.

This remarkable exception tends to prove the rule we should
anticipate namely, that tubercular meningitis is only re-
vealed to the mirror when it invades the anterior and inferior
parts of the encephalon ; and that the eye-symptoms, though
the rule, are yet in reality accidental, and depend upon the
locality of the mischief. In Mr. Hulke's cases, published in
the sixth volume of the ' Ophthalmic Hospital Reports,'
part ii., I find four in which meningitis was known or sup-
posed to coexist with optic symptoms. One of these patients
recovered. In another case death followed ; and in this optic
neuritis was succeeding the ' Stauungs ' papilla, as in my case

of Master O , but had not, as in my case, reached the

disk. Mr. Hulke points out that Stauungs papilla, or
ischsemia papilla, is not therefore pathognomonic of in-
tracranial tumour, as has been supposed by Graefe, but
here occurred as a consequence of meningitis of the base.
I pointed out the same thing in my lectures f On Optic
Neuritis/ published in the 'Medical Times and Gazette'
in 1868.

Mr. Hutchinson published in the ' Royal Ophthalmic
Hospital Reports' for December, 1866, a remarkable paper,

v.] INTRACRANIAL DISORDERS. 97

with tables, entitled 'A group of cases of Optic Neuritis
in Children/ It is quite unaccountable to me how I
managed to overlook this paper until after the publication
of my remarks upon Meningitis in the ' Lancet' for May I
and May 8, 1869. Mr. Hutchinson does not distinguish
between papillary ischsemia and optic neuritis, and the
latter he refers to 'arachnitis, cerebral tumours, and blood-
poisoning,' meaning, I suppose, by blood-poisoning, fevers,
pyaemia, syphilis, and the like.

Meningitis is, in many cases no doubt, the cause of the
' optic neuritis' in ' blood-poisoning,' as I shall prove in the
three classes of cases I have instanced. Mr. Hutchinson goes
on to say (p. 307), 'My attention has for some time been
drawn to a group of cases in which optic neuritis occurs

in children Nearly always there is a history of a

severe illness, which was supposed to be fever, and was
marked by delirium and other head symptoms. As the
child recovered from this it was found that blindness, either
partial or complete, had occurred. Frequently such children
regain good health, in fact recover perfectly, excepting as
regards the sight.' Mr. Hutchinson quotes also the case
of * an adult man, who had become blind after an illness
attended by vomiting, pain in the head, &c.' (p. 309). In
these remarks, and in the tabulated twelve cases which
follow, we have the surgical attitude in the matter. These
twelve patients saw Mr. Hutchinson, not because they had
suffered from meningitis indeed, it does not seem to have
occurred to Mr. Hutchinson that their symptoms were due
to meningitis but because they were more or less blind.
I have no doubt that all these cases were cases of recovery
from meningitis, and cases in which the optic nerves had
been seriously affected. In the majority of cases, perhaps,
the optic nerves are much less affected, and the sign can
be recognised only by the forewarned physician. Probably
in the majority, or the large majority of cases of mere
papillary ischemia, the nerves may recover their health and
function. I have quoted two of Mr. Hutchinson's cases
in the Appendix [Nos. 35 and 36]. I have long purposed

H

98 OPHTHALMOSCOPE IN [CHAP.

to look for such cases in an asylum for the blind, but
occasion has not favoured me.

I now ought to cite the experience of M. Bouchut, who
has used the ophthalmoscope in a large number of cases of
meningitis ; his observations are very important, though
M. Bouchut writes too enthusiastically about the ophthal-
moscope to secure my willing assent to all that he advances.

M. Bouchut, in his treatise published in 1868, states that
he had then examined and carefully noted the ophthalmoscopic
symptoms in fifty-nine cases of meningitis, and that he had
found symptomatic changes in the eye in all but two. Of
these two one was insufficiently examined, and the other
was of doubtful diagnosis and ended in recovery. I cannot
but think, however, that these cases would lead us to overrate
the frequency of neuro-retinal disturbance in meningitis. It
is also stated by M. Bouchut that the eye, on the side of
the main lesion in the brain, is more affected than the other,
and he says that in this way the mischief may be followed
from one side of the brain to the other. I do not attach much
weight to this statement : the causation of the optic symp-
toms is very indirect, and depends on such accidents as the
position of the mischief and its consequences in the venous
sinuses rather than on its extent. M. Bouchut supports
me in saying that although in many cases of meningitis
there can be little doubt of the disease, whether we use the
ophthalmoscope or not, yet that in other and more doubtful
cases the early appearance of changes in the eye may be of the
first importance. The same is true in the use of the stetho-
scope in phthisis.

- In Dr. Macnamara's treatise on Diseases of the Eye, there
are some very interesting observations on an injection of the
optic disk which accompanies headaches induced by over-
exposure to the tropical sun. He describes the disk as being
intensely congested, and the ' capillaries of the retina ' (sic) as
being slightly hyperamic. In fever too, brought on by over-
exposure to the sun, he says the disk ' becomes bright scarlet,'
and its nervous elements ' hazy and swollen, its margin being
ill-defined.' Macnamara supposes that the cerebral irritation

v.] INTEACRANIAL DISORDERS. 99

is due to advance of the solar irritation from the retina up-
wards, my view would be rather the reverse ; but autopsies
alone can finally settle the question.

1 must not conclude this section without some reference
to tubercle in the choroid as symptomatic of tubercular
meningitis. Dr. Moxon has been so kind as to send me
an account of such a case which recently occurred in Guy's
Hospital. Several such cases have been shown of late at
the Societies also; as, for example, by Messrs. Soelberg
Wells and Bowater Vernon, in the nineteenth volume of
the 'Pathological Society's Transactions.' Tubercle in the
choroid is of little value as a diagnostic sign ; it has only
the corroborative value that tubercle in the lung would
have; and, on the other hand, it is of too rare occurrence
to make its absence worth noting. As a pathological event,
however, it is interesting and instructive. Its occurrence
was first pointed out by Manz 7 , who published three cases
of tubercle of the choroid. Cohnheim 8 then pushed the
matter forward to the extent of asserting that tubercle is
to be found in the choroid in almost all cases of acute
miliary tuberculosis, and he found it in the choroid of a
pig which had been inoculated with tubercular matter.
Cohnheim is certainly wrong in supposing that tubercle
occurs so frequently in the choroid. For three years past
I have examined all the cases of miliary tuberculosis in which
an examination could be managed, and have not found
tubercle of the choroid in a single instance. I may have
examined ten cases in all. In two cases I have examined
the choroid after death with negative results. In both
these cases tubercle was numerously present in all three
cavities. Grafe and Leber have gone into the whole ques-
tion again 9 . They give two cases in which tubercle of the
choroid was diagnosed during life and found on post-mortem

7 Vid. 'Archiv. f. Ophth.' Bd. iv. Abth. ii. p. 120, and Bd. ix. Ab. iii.

P- 133.

8 Virchow, 'Archiv.' May, 1867.

9 'Archiv. f. Ophth.' xiv. Ab. i. p. 183 ; vid. also Grafe, 'Ueber Aderhaut-
tuberculose/ Berl. Klin. Wochenschr. (1867), No. 31.

H 2

100 OPHTHALMOSCOPE IN [CHAP.

examination. In the first case, a man under the care of
Griesinger with tuberculosis of the pia mater, the eyes were
examined by Von Grafe, who found spots of tubercle in the
choroids. After death miliary tubercle was discovered in
the pia mater, and scattered through the body, and their
presence in the choroids was verified.

In the second case, a child aged fifteen months, under the
care of Dr. Frankel, the eyes were examined by Dr. Leber.
Eight spots of tubercle were seen in the left, and two in
the right choroid. During the time of the child's illness
these spots grew larger and became more evident. It is
quite possible that the discovery of tubercle in the choroid
might help in the diagnosis of an obscure case, but as yet,
I think, it does not occur with sufficient frequency to raise
it out of the domain of pathological curiosities. When it
does appear, however, it has this advantage, that it reveals
the morbid process to us in its kind, which cannot be said
of any other of the phenomena of medical ophthalmoscopy.

The microscopical appearances of tubercle in the choroid
are well described by Cohnheim (loc. cit.) in seven cases.
He found the number of nodules very various, the smaller
being transparent and the larger being caseous in the centre.
They begin on the retinal surface, but when large (i millim.),
reach as far as the sclerotic surface. Cohnheim traces their
origin to lymphoid cells, and not to connective tissue cells,
which bears out the observations of Sanderson. In all his
cases there was abundant tubercle elsewhere. Tubercle may,
however, exist in the choroid when it does not exist in the
meninges of the brain; this is proved by one of Steffen's
cases, in which tubercle of the choroid co-existed with acute
tuberculosis, but without meningitis.

Tubercle of the choroid does not generally cause loss of visual
power, but I have seen a case quoted from Barozzi (<Gaz.
Med. d'Orient. Fev. J 1869), in which tubercle of the choroid
caused blindness of the left eye a month before death. There
were four tubercles near the disk, and there was a detachment
of the retina which no doubt was the direct cause of the
loss of sight. I have not seen the original account, but

v.j INTRAORANIAL DISORDERS. 101

it seems that no autopsy was made. There was, however,
evidence of tubercle elsewhere.

B. Meningitis in Fevers, Erysipelas, Pycemia, fyc.

In passing- on to consider the effect of these kinds of
meningitis upon the eye, I have to repeat that the nature
of the disease, whether suppurative or other, has little to
do with the occurrence of the eye changes, unless it be
that phlebitis and occlusion of the sinuses be more common
in the suppurative forms, but that its position is the im-
portant matter. Meningitis of the base of the encephalon,
whatever be its kind, is very commonly accompanied
sooner or later with disturbance of the vascularity of the
back of the eye, and, in more protracted cases, descending 1
neuritis often appears at the disk. Now, meningitis born
of causes from within is very commonly basilar, if we except
the chronic meningitis of drunkards we may perhaps say al-
ways basilar; while meningitis which results from an injury
from without or from caries, need not be, and very commonly
is not situated at the base. I say, meningitis which ac-
companies internal changes, though by no means always,
is yet very commonly at the base, and even when a large
tract and various districts are affected the base is generally
included. I suppose this depends upon some greater ir-
ritability or vascularity of the membranes at this part.
The meningitis which occurs in the eruptive fevers, in
erysipelas and pyaemia seldom spares the base of the en-
cephalon ; and in the ophthalmoscope we have a valuable
means of ascertaining whether this state be present or not.
Is the violent delirium in a given patient due to meningitis,
or is it only due to some functional disturbance in the
encephalon and its vessels, is often an anxious question with
the physician, and the help which we obtain from the oph-
thalmoscope is our only means of answering this question
in a large number of instances. My own impression from
such experience as I have is that this help is often of great
value ; my experience, however, is *as yet too limited to

102 OPHTHALMOSCOPE IN [CHAP.

enable me to speak decidedly. I have examined the eyes of
many patients in typhus and enteric fever who suffered
from head symptoms, and in the majority I found nothing ;
in three fatal cases, however, I saw ophthalmoscopic evidence
of the meningitis which was found after death to have been
present. In five more cases I saw evidence of meningitis,
as I suppose, which ended in recovery of health, but in
partial or complete loss of sight ; and in two cases I found
excessive vascularity at the back of the eye, which subsided
during convalescence. That loss of sight occasionally follows
the continued fevers has long been noticed by clinicians, and
is, I believe, in all cases due to meningitis 10 . [Vide Appendix,
Nos. 40-46.]

Stellwag von Carion gives a remarkable case in which
he saw optic neuritis in the eyes of a patient in typhoid
fever. Some years later this patient died of some other
disease when old organized exudations were found in the
membranes at the base of the brain. This is a most re-
markable case, and cases of the kind might often, no doubt,
be discovered in our asylums.

Von Carion also says (' Dis. of Eye,' Trans. Lond. 1868,
p. 672), that in rare cases the optic atrophy does not
appear until long after the disappearance of the meningitis,
and that it is then due to cicatricial shrinking and obliter-
ation of the portions of the membranes which have been
inflamed. He adds that in such cases the autopsy here
shows actual tying together of the nervous cords by cica-
tricial tissues. This seems to me one of those plausible
descriptions which may turn out to be purely imaginary.
I have, however, a very remarkable case under my charge

at present. A young woman, Barbara H , now aged 14,

had 'fever' when three years old. She seemed to get well
at the time, but has been liable to attacks of vomiting ever
since. During some years they recurred once a fortnight,

10 Cases are frequently described of optic atrophy, with or without some
neuritis, as following diphtheria, &c., and due to the ' dyscrasia.' Such ex-
planations, especially if without autopsies, as is commonly the case, are too
subtile for my handling.

v.] INTRAGRANIAL DISORDERS. 103

but during last three years every week. The attacks last
two or three days, and are preceded by drooping of the
left eyelid for twenty-four hours antecedently. In both
disks there is subacute neuritis, due to long-continued
f Stauungs-papillse.' She is not conscious of loss of sight,
but on testing she cannot read small pica easily with the
left eye.

I have notes of the optic nerves in three cases of pyaemia.
In two of these cases, which occurred in private practice,
I examined the eyes during life, and found in one that
the appearances were normal, while in the other there was
a well-marked ischemia in both disks. I heard nothing
more of either case. The third case occurred in the
Wakefield Asylum [Appendix, No. 45]. I did not examine
the eyes during life, but Dr. Browne was so good as to
investigate the state of the optic nerves for me after death.
He found limited meningitis with some exudation about
the chiasma and a highly injected state of both optic trunks.
It is probable that in this case there would have been
visible changes in the vascularity of the disks during life.
The patient died delirious, but with no marked symptoms
of meningitis. I am sorry that I had not the nerves for
microscopic examination. The occurrence of optic neuritis
in connection with pyaBmia is mentioned by several writers,
but no doubt in many of these cases the change was rather
ischa3mic than neuritic.

I hope the use of the mirror will not be omitted by those
in charge of our fever hospitals. The permanent amaurosis
which is often said to have followed measles, scarlet fever,
small-pox, &c., is probably of like causation, and the mirror
may give us important information concerning any severe
delirium, or other head symptoms occurring in consequence of
these fevers. I have but few notes of personal observation in
such cases. Cerebrospinal meningitis is a fever which I have
never seen ; in it extensive mischief often appears in the eye,
and mischief which would make it impossible to see the fundus.
* Optic neuritis ' has, however, been noted in several cases ;
as, for example, by Schirmer, ' Klin. Monatsbl. f. Augenh./

104 OPHTHALMOSCOPE IN [CHAP.

1865, p. 275 ; and Mr. Wilson says (' Dublin Quarterly Jour-
nal/ May 1867), that f amaurosis is not an uncommon se-
quence of cerebrospinal meningitis.' It seems likely that the
mischief commences in the inner coats ; but I am disposed to
suspect that choroiditis rather than neuro-retinitis is the first
disorder. I am disposed to be of this opinion because a curi-
ous state of the inner coats of the eye has been described in
puerperal fever, which is worth an allusion in this place,
though it partakes rather of the nature of general ophthal-
mitis. It consists of a purulent choroiditis, and is inter-
esting, inasmuch as it may throw more light upon the pro-
cess of capillary embolism so well described by Bastian and
others, and also as it seems to lead on to that more general
destruction of the eye which is seen in epidemic meningitis.
I know nothing of this puerperal choroiditis of my own know-
ledge, and am entirely indebted for my information to a paper
by Knapp in the c Arch. f. Ophth/ xiii. i. The paper is a long
one, and well illustrated. Knapp describes the parts in three
cases. The purulent inflammation begins in the chorio-capil-
laris, and is apparently due to capillary infarctions which
soften and break up in pyoid forms. From this layer the
inflammation extends to the stroma of the choroid, which
proliferates and runs down into fat and pus, and thence the
retina, the pars ciliaris, the vitreous humour, and even the
capsule of the lens are invaded. The process seems to recede
before perforation takes place. If this plugging and purulent
change be traced out in the ohorio-capillaris, it will be a fact of
great interest and importance in connection with the hypo-
thesis which attributes a like origin to the other local forma-
tions of pus in pyaemia.

This is, perhaps, the place in which to discuss the peculiar
and singularly interesting changes observed in the fundus in
cases of cholera, by Von Grafe n . After describing the well-
known sunken, upturned, bloodshot, and dry eye-ball, he says
of the changes seen with the mirror, that, except in the final
agony, the circulation in the retinal vessels is always to be

11 'Ophthal. Beobacht. bei Cholera/ Arch. f. Ophth. vol. xii. part ii.
p. 198.

v.] INTRACRAN1AL DISORDERS. 105

made out, although the branches of the central artery are
extremely thin, as may be seen also in other states of general
disorder. But in striking contrast to the pale and half-filled
arteries are, in the stages of asphyxia at least, the veiy dark,
even blue-red veins which are visible up to their finest rami-
fications, without, however, being very full or very tortuous.
Not infrequently the aspect of the disk is also changed, and
instead of the uniform rosy tint of health, it appears of a pale
lilac. There does not seem to be any loss of visual power.
These very interesting observations are one more proof of the
value which the eye mirror may be to us in ascertaining the
kind of changes which the circulation of the brain under-
goes in asphyxia and in various other kinds of general
disturbance. Finally, I must warn the reader against the
supposition that the transient debility of vision, which often
follows or accompanies severe constitutional disease, sig-
nifies meningitis, or indeed any other organic disorder,
unless it be a remediable anaemia with or without oadema
in the optic nerves and base of the encephalon. The disk
may be white and the vessels small in these states, or there
may be some opalescence of the fundus ; the field of vision,
however, such as it is, remains complete, and the functional
deficiency passes away in a few days or weeks under tonic
and nutrient treatment. Paresis of accommodation often
accompanies this kind of amblyopia ; and Dr. Hughlings Jack-
son makes the interesting remark that diphtherial paralysis
differs from all other kinds of paralysis with which he is
acquainted in seeming to have a great preference for those
branches of nerves which pass through the ganglia of the
sympathetic. For instance, in the so-called diphtheritic
amaurosis the whole of the third nerve is not paralysed,
but only those branches which pass through the lenticular
ganglion. The facial is not paralysed, but those branches
of nerves given off by Meek el's ganglion to the palate. Next,
as to the otic ganglion. Hearing is practically not affected
at all in the general run of cases, as the accessory muscles of
the ear have far less to do with the functions of the organ of
hearing than the ciliary muscle has with sight. But in one

106 OPHTHALMOSCOPE IN [CHAP.

case, that of a well-educated medical man, notes of which had
been furnished to Dr. Hughlings Jackson, there was slight
defect of hearing. It was not enough to render the patient
unable to converse, but, to use the patient's expression, it
' rendered music unintelligible/ Next, there was in this case
too, defect, not loss, of taste, due probably to an affection of
the branch of the facial (the chorda tympani), given off to
the submaxillary ganglion.

C. Syphilitic and Rheumatic Meningitis.

These two forms of meningitis, like the tubercular, are
proliferative and affect chiefly the base. One of them is so
common that I need not here spend time and space upon
it, while the other will receive as scant measure for the
opposite reason, namely, that it is almost unknown. Of
rheumatic meningitis there appear to be two kinds; the one
kind resembles, both in character and time of appearance,
the other serous inflammations which attack in the course
of rheumatic fever, while the other is a very chronic process
attended with thickening and adhesion. My information
concerning these states is almost entirely derived from the
treatise of Gintrac 12 , for I have no experience of either of
them. I have seen four cases of so-called ' cerebral rheu-
matism' with very high temperature; one of these recovered,
and in the three which died no meningitis was found, but
only the congestion usual in such cases. Probably many
cases are reported as meningitis in which no such process
existed. I examined two of the cases alluded to with the
mirror, but saw nothing abnormal unless it were some ful-
ness of the veins. The mirror may have the power of
distinguishing between the presence and absence of menin-
gitis in these terrible cases. Of chronic meningitis following
rheumatic fever, I have seen but one case, and in this I
have not the control of an autopsy. It occurred in a man
named Abraham Waddington, set. 35, who was admitted
into the Wakefield Asylum for violent mania, which was

12 'De la Meningite Rheumatismale,' Bordeaux, 1865.

v.] INTRACRANIAL DISORDERS. 107

a sequence of rheumatic fever. From the symptoms which
continued during a long period of subsequent observation,
Dr. Crichton Browne believed that chronic meningitis was
present. When I saw him he had much improved, and
was, for the time at least, in a very manageable condition.
With the right eye he could read No. 6 (Jager) with diffi-
culty, with the left eye No. 3 with difficulty. Both disks
were distinctly though not extremely atrophied, the right
being worse than the left 13 .

My experience of syphilitic meningitis, on the contrary,
has been considerable, and I can appeal to much experience
embodied in many careful essays from that of Thomas
Reid to the present moment. It is unnecessary for me
therefore to add to this volume any more cases or much
explanation in this place ; but I may refer the reader to
my paper on ' Syphilitic Disease of the Nervous System,'
in the fourth volume of ' St. George's Hospital Reports/
Active proliferation is very significant of this affection ;
though partial it often affects the base, and especially that
part of it which lies on the basilar process, so that the
nerves of the face are very frequently involved. True
neuro-retinitis propagated downwards to the eye is a very
common accompaniment of this disease, the connection being
more certain than in any other meningitis. Ischaemia of
the disks is less common in this form, but atrophy of a
primary kind is not uncommon 14 , and depends upon an
intracranial severance of the optic nerve due to strangling.
It is very important to examine the disks in all cases of
suspicious headache; for in such I have often found neuro-
retinitis, a discovery which of course is important in many
ways. I will only add that syphilitic neuro-retinitis is more

13 There are certain palsies of the orbital muscles which are recognised as
rheumatic by ophthalmic surgeons. These palsies do not form part of the
present chapter, and if they be mere muscular conditions they will not form
any part of the subject. If, however, they are found to consist in any visible
disturbance of the nutrition of the nerves, they may throw light upon many
points of interest to the student of nervous affections.

14 I found it, for instance, in a case the details of which, with the autopsy,
were published by Mr. Lawson Tait in the ' Medical Times ' for Feb. 1869.

108 OPHTHALMOSCOPE IN [CHAP.

amenable to treatment than other kinds, and may some-
times be cured by anti-syphilitic remedies and atrophy thus
averted. Syphilitic neuro-retinitis is, however, nearly al-
ways well pronounced and, as it is common, no cases make
better specimens for students or beginners in ophthal-
moscopy. Syphilitic retinitis is described in a subsequent
chapter of this volume.

D. Meningitis of Drunkards.

This is a very chronic change ending in thickening and
opacity of the membranes, especially over the convex sur-
face of the encephalon. It is familiar to the medical officers
of asylums, and it is there that I have met with it. It
seems to affect the base much less than the convexity, and
I do not know that it has any effect upon the optic nerves.
These are often degenerated in drunkards, and the vessels
injected, but these effects do not seem to be due to any
meningitic process.

E. Traumatic Meningitis.

Traumatic meningitis, like the pyamic, is commonly sup-
purative, but it differs from the pya3mic in having little pre-
ference for the base. The mirror is seldom of use in these
cases ; they rarely present much difficulty of diagnosis, and
unless the mischief be at the base, the meningitis around it
will not interfere with the optic nerves. Sometimes, indeed,
this inflammation spreads away from its point of origin, and
if it spreads over the encephalon it may well affect the base
also ; but any optic signs in such a state of things would have
but little importance beyond that of mere curiosities. In
some cases of traumatic meningitis, indeed, I have found the
mirror of some use, and that is in cases of caries of the pe-
trous bone resulting from disease of the ear. The occurrence
of marked changes in the disks in such cases is a very serious
event, but we have no means of distinguishing whether they
are due to abscess, to meningitis, or to phlebitis and throm-
bosis of the sinuses. I make a practice, however, of examining

v.] INTRACRANIAL DISORDERS. 109

the eyes in all cases of suppurating- ear. Vide Appendix, Nos.
42, 43. For some further remarks on this subject I may
refer the reader to my sections on Encephalic Abscess and
on Fracture ; also to Dusch's monograph on Thrombosis of the
Cerebral Sinuses, published by the Sydenham Society.

VI. CONCUSSION AND FRACTURE.

I have no experience of the optic nerve in cases of recent
concussion save this, that I have examined some half dozen
cases with negative results. In these cases, however, I had
no reason to expect any visible changes, as the only defects
of the special sense seemed to be those of indefinition or illu-
sion, which might well depend merely upon changes in the
encephalic centres. Cases, however, do occur, and occur fre-
quently, in which there may be some more decided interfer-
ence with the perceptive power of the retina, or with the con-
ducting power of the nerve. Mr. Le Gros Clark, in his Lec-
tures on surgical diagnosis, gives a very remarkable example
of this kind. He says (p. 52) : * A youth who had fallen on
his head was admitted, with slight concussion, into the hos-
pital. His most marked symptom was loss of vision ; he
could not even perceive light. This condition was very tran-
sient ; in half an hour he could just detect the presence of
my fingers when interposed between his eyes and the bright
daylight ; and in the course of another hour he had recovered
natural vision. He made a speedy recovery/ Mr. Clark is
disposed to refeT the blindness rather to the encephalic centre
than to the retina. However this may be, we have here and in
like instances good examples of the remarkable occurrence of
functional arrest in nervous parts which are supposed not to
be structurally degraded, but to have assumed perhaps some
isomeric state. That the optic nerve in such states is not
obviously injured, it is the interesting part of the ophthalmo-
scope to discover ; and we have here one more instance of the
important fact that changes of a congestive, inflammatory, or
atrophic kind in the disks must have some time for their
development.

110 OPHTHALMOSCOPE IN [CHAP.

If we leave cases of recent concussion, however, I come
upon so large a number of cases, both in my own practice
and that of others, that I have no lack of materials, whatever
use I may make of them.

When I omit all reference to railway accidents, which are
full of pitfalls for the enquirer, and take only cases where there
is no likelihood of deception, I still find a large number in
which amaurosis has followed a blow upon the head. In pass-
ing, let me say, first of all, that in a very formidable number of
cases of syphilitic intracranial disease, and of tumour, we have
a history of a blow. Like other observers, I had long been in
the habit of disregarding the blow, as we know but too well
how natural it is in seeking for a cause to fix upon the most
conspicuous antecedent; and this is especially true of the
class of patients who frequent hospitals. Not in hospital
practice alone, however, but in private practice also, and in
circumstances where I have been able to weigh and compare
statements, I still find that we have histories of blows on
the head at spots where a tumour or syphilitic mischief is
subsequently found. In three several cases have I found a
glioma, a hard sarcoma, and a vascular sarcoma respectively
within skulls which had undoubtedly been hit hard on the
region above these neoplasms. So many of my patients with
intracranial syphilis have complained of blows as the cause to
be blamed for the event, that at one time I began to wonder
whether concussion of the base was the cause which deter-
mined syphilitic pachymeningitis to this region. I shall be
glad if any of my readers who have observed that a syphilitic
outbreak within a skull followed a blow upon it, or that the
growth of a neoplasm in like manner followed such a blow,
will tell me of the case 15 .

The remote events, however, which usually follow severe
concussions, with or without fracture, are four haemorrhage,
abscess, meningitis, and sclerosis. The two latter events

15 While correcting this proof I happened to meet Dr. Hughlings Jackson,
and this question came up. He was much in favour of my supposition, that
blows do in many cases determine an outbreak of intracranial syphilis. I
think a like causation may hold in syphilis of the shins.

v.] INTRACRANIAL DISORDERS. Ill

favour the occurrence of amaurosis, and we may sometimes
distinguish between them with the mirror. I give several
cases of secondary meningitis in the Appendix (Nos. 53, 54,
56), and I may refer especially to the cases recorded by Mr.
Hutchinson and Dr. Slack (Nos. 53 and 64). Sclerosis of the
brain mass below the seat of a blow has been found in
many cases, and the hardened portion is sometimes called
a tumour. Cases Nos. 58 and 59 in the Appendix, which I
quote from Mackenzie, and Case 60 from my own notes, are
good instances of this kind of change, with its ultimate effects
upon the optic nerves. I fancy this may be a commoner
cause of amaurosis than meningitis, especially if atrophy be
the first stage in the change, and I must refer to the
section on Sclerosis for further explanation of the mode of it.
While meningitis will often produce neuritic symptoms,
sclerosis will always produce primary atrophy. The effects
of abscess in causing optic changes are also discussed
elsewhere, as are the effects of haemorrhage. I have
said that recent haemorrhage has no power over the
optic disks ; and if an old haemorrhage affects them, it is
probably by intermediation of sclerosis, so that abscess or
meningitis may be paired together as links between blows
on the head and amaurosis, while haemorrhage retires behind
sclerosis.

In cases of fracture we find, if we direct our attention to
the bones only, that affection of sight is a rare consequence,
though many instances of this kind of interference are re-
corded. When fracture sets up secondary meningitis about
the base, the consequences may well be seen in the disks, but
such signs would form too small a part of the assembly of
symptoms to be worth much in diagnosis. For my own part
I have examined about a dozen cases of fracture, but if a
slight dimness of outline be excepted, I have never discovered
any important changes in the fundus. If such changes
do occur, not as a consequence of meningitis, but as a direct
result of the fracture, the nerve is either compressed by a dis-
placement, or the same kind of ecchymosis occurs in the
retina or nerve which is commonly seen in the conjunctiva,

112 OPHTHALMOSCOPE IN [CHAP.

and for the same reasons. Examples of all these results are
given in the Appendix (Nos. 61, 62, 63, 64). In one case of
fracture which I examined with the mirror, the left eye-ball
was full of blood. Amaurosis as a direct result of displace-
ment of bone, or of very limited meningitis, is more likely to
be unilateral than when it results from other changes, except
in the one case of aneurism of one anterior cerebral artery.
I suppose extensive haemorrhage at the base, or indeed any-
where upon the encephalon, might cause neuritis or atrophy
of the disks if it took on the cystic change and became an
intracranial tumour.

VII. HYDROCEPHALUS.

Hydrocephalus, or simple dropsy of the brain, is very de-
structive to the optic nerves, and blindness is often due to
this cause. Ischsemia papillae seems in many cases to be the
earliest change, as I have certainly noticed it in early cases
more than once. Herein I am obliged to differ from Grafe,
who has only found simple white atrophy in cases of hydro-
cephalic amaurosis. It is likely that Grafe,, however, does not
see hydrocephalic children until the mischief is old and the
loss of sight obvious. If the affection be at all extreme, the
disks and retinas become wholly disorganised, and the optic
nerves become atrophied from pressure, or from abolition of
their function. With the mirror we see the disks atrophied,
their outlines blurred or lost, the vessels distorted or closed,
and brownish or whitish patches, blotches, and streaks upon
the retina ; some of these being old hemorrhages, others exu-
dations and fatty degenerations. I believe these changes are
mainly due to pressure, or severance of central connections,
though it would be difficult to deny that some subinflammatory
action and proliferation is often mixed up with the death by
over- distension and prevention of nutrition. A dropsical
effusion pressing down the floor of the third ventricle will, of
course, tend to press upon the chiasma. M. Bouchut says
that with the mirror we may distinguish the large square
heads of rickets from hydrocephalus. He would say, then,
hydrocephalus had occurred in the course of rickets in the

v.] INTRACRANIAL DISORDERS. 113

following case of a little child formerly under my care at the
infirmary 16 . She was about three years old and the youngest
of the family. There was a distinct history of rachitic symp-
toms, enlargement of the ends of the long bones, and some
abnormal curvature in their length. The chest was character-
istic also. The face was square and the head large, but neither
its size nor the state of the fontanelles was sufficient to enable
us to diagnose hydrocephalus. With the mirror the disks
appeared swollen and vascular, and the retinal veins dis-
tended. I have lately admitted another little child of weakly
constitution into the infirmary, whose eyes I examined simply
to show one of my pupils how to examine the eyes of children.
To my surprise I found atrophy of the optic disks to the
second degree. On enquiry from the mother I learned that
the child, which was nearly a year old, had not begun to
' take notice ' as she had hoped, and I believe it was half
blind. I watched the child carefully. In a fortnight after-
wards its head began to enlarge, and in three weeks more
had attained a considerable size. The child is now distinctly
hydrocephalic, and is not improving under treatment. There
have been no symptoms of meningitis. Here, we probably
had simple atrophy as the first optic change, and in every
point of view the case is one of great interest. It teaches us,
among other things, that the eyes of all children which ' take
notice ' late ought to be examined with the mirror.

Tumour or other encephalic diseases often act upon the eye by
the mediation of hydrocephalus. A case was lately recorded in
the ' Lancet' (March 21, 1868), in which there was cerebral
dropsy due to the pressure of a cyst upon the venae Galeni.
The child is reported as ' having the special senses, sight, &c.,
perfect/ The case passed out of notice, and when seen again
blindness is reported. No doubt changes in and near the
disk might have been seen long before much disturbance of
vision was noticed. I must warn the reader against accept-
ing any cases on the negative side in which the mirror was

16 Dr. Dickenson, in the 'Lancet,' July 16, 1870, says that of twenty-six
hydrocephalic children which had come under his care, signs of rickets were
noted in nineteen.

I

114 OPHTHALMOSCOPE IN [CHAP.

not carefully and repeatedly used. When, on the use of the
mirror, we find ischaemia papillae, we should infer that the
pressure is upon the venous system ; when we find atrophy,
we should infer that the optic changes are rather due to
pressure within the ventricles upon the thalami, and through
the crura cerebri upon the tracts, or downwards upon the
chiasma. There seems to be no doubt that tumours of the
posterior part of the cranium, such as tumours of the vermi-
form process of the cerebellum, do act upon the optic disks
by the intermediation of hydrocephalus, which is due itself
to pressure upon the veins of Galen, or upon the lateral
sinuses, or perhaps to closure of the communication between
the fourth ventricle and the subarachnoid space described by
Mr. Hilton 17 . I cannot say whether in cases of suspected
hydrocephalus, as, for instance, in the large head of rickets,
the absence of ophthalmoscopic signs has any or much value
in diagnosis. A good deal of experience is necessary to de-
termine such delicate points as these ; I am disposed, however,
to think that the absence of such signs should claim a place
among other considerations.

VIII. INTRACRANIAL TUMOURS.

It is with much hesitation that I enter upon the section of
encephalic tumours, for this is the classical ground of medical
ophthalmoscopy. It was to the diagnosis of encephalic tumour
that Von Grafe first applied the mirror, and he based upon such
observations his well-known introductory paper in the seventh
volume of his 'Archives'' (for 1860), ' On the Complication of
Optic Neuritis with Diseases of the Brain.' Since that time
cases of tumour have formed the staple of similar observations
made by himself and many others up to the present time.
I had fair grounds for hoping therefore that with such ma-
terials I should find myself in a position to sum up more or less
conclusively what has been said on this part of the subject, if
not to formulate with something like completeness a series of

17 Dr. Dickenson has again demonstrated this opening, and proved that it is
traversed by a fluid so thin as the cerebrospinal fluid.

v.] INTRACRANIAL DISORDERS. 115

definite propositions. It is with a sense of disappointment
however that I find myself, at the end of much reading and
of much clinical observation, very far from any such results.
I am not in a position even to indicate, with anything like
finality, the actual value of the presence or absence of optic
change in the diagnosis or exclusion of encephalic tumour;
nor am I able to say with anything like certainty what are
the intermediate processes which connect these changes in the
head with inflammatory or congestive changes in the disks.
I must content myself then with the humbler task of re-
vising and setting forth the facts as they seem to have been
made out by myself and others, and must still look forward
to the time when these facts shall be comprehended in some
more general laws.

Encephalic tumours are not among the common things of
practice, even in the practice of those who, like myself, are
connected with large hospitals. Still less commonly can we
trace these cases from their clinical beginnings to their patho-
logical ends. The cases are tedious, they go from place to
place, and from doctor to doctor, and at last die when we are
least expecting it, or are least able to secure an autopsy. The
number of cases of encephalic tumour which have passed
before me must no doubt be considerable, and these have in
many instances been well watched for a time, but I cannot
even now count more than eight cases which I have watched
from first to last in life, and have examined after death, and
eight cases is but a small number to reason upon. I fear it is
a deceptive process to make up cases by tacking fragments
together, but it seems that if I wait for more complete ones
I may postpone publication indefinitely. In like manner I
might postpone this work even longer did I wait to attain to
a clear perception in my own mind of the nature of many of
those processes in nervous pathology, which nevertheless bear
very closely upon the interpretation of changes secondary to
encephalic tumour.

Another difficulty there is in this, that the great majority
of published cases of tumour are useless for our present
purpose. With the beaver-like instinct of an animal collecting

i 2

116 OPHTHALMOSCOPE IN [CHAP.

materials for a book, I had made a catalogue of a vast
number of cases, both from home and foreign journals and
from treatises on encephalic diseases. Taking Ladame's ca-
tegories as a basis, I had added so many new cases that a very
formidable list was obtained. But when I came to analyse
this list, which had cost so much trouble, and from which
I hoped to obtain at least some rough generalizations, I was
obliged to admit that it was almost useless. I became con-
vinced that it was impossible to give any importance whatever
to those cases in which no mention was made of loss or dis-
turbance of sight, nor could I attach much value to the
majority of those in which vision was actually declared to be
unaffected. If the reader has followed me to this point, I have,
I hope, convinced him that even a careful testing of vision
can have no value whatever in the opinion of any observer
who knows how marked the changes may be in the fundus
of an eye which nevertheless can see well, or can see well
enough to satisfy a patient .struck down with mortal disease.
Changes in fact of a congestive kind may no doubt be
present throughout the duration of the malady without
giving rise to any visual disturbance whatever, and neuro-
retinitis has been recorded in cases of tumour where vision
was never in the least degree affected from first to last.
(Vide e.g. Appendix, No. 91, &c.) Nay, more, in those
cases of encephalic tumour in which the mirror has actually
been used, and its revelations recorded, we find many recorded
in a very unsatisfactory way, or more commonly we find that
the mirror was used once only in a case which lasted perhaps
one or two years. To say from such an observation that the
optic nerve was not implicated, is of as much value as to
record the fact that the patient's limbs were examined on a
certain morning and were found to be unpalsied. Though
I do not regret that I have made the list, I feel however that
for these reasons I must not add to the cost and size of this
little book by publishing it. On the other hand, if the general
question be asked, Is the ophthalmoscope of any use in the
diagnosis of tumours ? this question must be answered de-
cidedly and emphatically in the affirmative. Although we

v.J INTRACRANIAL DISORDERS. 117

cannot yet say exactly when to expect eye symptoms, what
conclusions to draw from them when present, or finally, how
to explain their occurrence in many cases, yet I hope to show
that some information of a very important kind is to be had
in this way. When a case comes before us in which ence-
phalic tumour may be present, the following questions among
others present themselves for reply :

1 . Is the case one of encephalic tumour at all ?

2. If so, what is the nature of that tumour ?

3. Of what size is it ?

4. Where is it situated ?

We may soon reduce these four questions to two, for the
purposes of our present enquiry. With the second question we
have not indeed to deal, for the ophthalmoscope is a clinical
rather than a pathological instrument. It has certainly been
made an objection to the value of ophthalmoscopic researches
that the changes in the eye, if present, can tell us nothing
of the nature of the intracranial tumour. Of course I admit
that the Discovery of cancer or of tubercle in the eye is of too
rare occurrence to give any meaning either to their presence or
their absence. But what does hemiplegia tell us of the nature
of cerebral tumours ? Nay, what does the stethoscope tell us
of the nature of pulmonary changes? It gives us only an
evidence of changed physical conditions, and every physician
knows how misleading this evidence may be, if it is not
weighed with all the other circumstances of each case.

The third and fourth questions are really one, for the
tumour is situated in every part to which it extends. We
have then to enquire, first, whether any given case be one of
tumour or not, and if so, then what parts the tumour oc-
cupies at any given time. Under the name of tumour it is
convenient to include also cysts, aneurisms, exostoses, collec-
tions under the dura mater, &c., as well as sarcomatous, gli-
omatous, tuberculous, carcinomatous growths, and the like. A
tumour will then be for us any enlargement or thickening
encroaching upon the intracranial chamber.

The frequent occurrence of dim vision or of blindness in
connection with encephalic tumour has long been known, and

118 OPHTHALMOSCOPE IN [CHAP.

before the eye-mirror came into use, the disturbance of vision
was counted as a common symptom. Friedreich 18 found
disturbance of sight to occur in twenty-six out of his forty-four
cases, and Ladame, who tabulates 331 cases, estimates the
disturbance of vision to occur in about one-half of the whole
number. These estimates are founded of course upon the
rough evidence of the patients themselves. In many cases, no
doubt, slight visual defects have been overlooked or regarded
as unimportant or uncertain, and undoubtedly in many more
cases the eye-mirror would have revealed changes at the
back of the eye which no other means could have detected.
Dr. Hughlings Jackson, whose cases of encephalic tumour
are controlled by skilful ophthalmoscopic examination, says,
' Tumour is nearly always attended by optic neuritis.' ('Medical
Times and Gazette/ Aug. 15, 1868.) My own opinion cer-
tainly is, that changes either of a congestive, neuritic, or
atrophic character may be found in the disks at some time
or other in the course of almost all cases of intracranial
tumour. The diagnosis of a case of this kind is therefore
incomplete unless the eye-mirror has been carefully and repeat-
edly used. It being thus conceded that changes in the optic
nerve are a frequent, though not perhaps a constant, accom-
paniment of intracranial tumour, we have to enquire, in the
next place, what are the conditions of this coexistence, in
order that we may know, if possible, when to expect it, and
what conclusions to draw from it when present. We shall
see presently that the situation of the growth has much to do
with the appearance of the changes in the disks, and also with
the time of their appearance. But we must be satisfied, if
possible, as to the mode of the initiation of the papillary
congestion, optic neuritis, or atrophy which we may discover
before we can hope to obtain a knowledge of the processes by
which they are established. I had thought that the way was
clear to the establishment of the intermediate changes, and
in the former parts of this book I have laid down certain
inferences concerning their nature which I supposed to be

18 Friedreich, Beitrage z. Lehre v. d. ' Geschwulsten innerhalb der Schadel-
hbhle.' Wurzburg, 1853.

v.] INTRAGRANIAL DISORDERS. 119

unquestionable. Since those parts were written, however, the
attribution of changes in the nutrition of the optic disk to
pressure, or to the travelling downwards of irritative action,
has been seriously disputed. I have not re-written my earlier
chapters, because I still hold the views therein expressed, but
the importance of the counter hypothesis, and the eminence of
its supporters, are such that I take occasion in this place to
reconsider the causation of neuritis and atrophy. Regarding
pressure and travelling irritation as insufficient to explain the
phenomena of optic neuritis and atrophy, another hypothesis
has been substituted for these which is said to have greater
explaining power.

I do not know who is to be called the author of this newer
hypothesis, but I find it clearly laid down by Benedikt 19 in
1868, and I believe that it has been adopted in England
by Dr. Hughlings Jackson. I cannot therefore dismiss it
without very careful discussion, and the question is worth
discussion, for it bears not only upon optic neuritis, but upon
the interpretation of many other secondary changes in the
nervous system.

I shall set forth the new hypothesis in Benedikt's own
words, and shall then proceed to test its strength. After
urging, as Dr. Jackson and myself have so constantly done,
that every case of disease of the nervous system must be
watched with the eye-mirror, ' for very often a high degree
of neuro-retinitis will continue for a long time without any
disturbance of vision whatever,' and after referring to the
curious constancy of the bilateral change, and that the changes
occur in connection with mischief which is far away from the
nerves themselves, as, for instance, in the case of tumours of
the pons and of the cerebellum, he proceeds as follows, in
a passage which I think it well to translate word for word, as
the original may not be easily accessible :

* Ophthalmologists have long known these facts, though in
connection with another set of ideas. The conception has gained
ground everywhere that the trophic disturbances are due to
disturbances of the circulation set up by direct or indirect

19 ' Elektrotherapie,' Wien, 1868, p. 249 and aeq.

120 OPHTHALMOSCOPE IN [CHAP.

pressure (a). This view can only be directly proved in a few
cases, and in many cases it has no precise significance. If,
for example, as was the fact in one of my cases [recorded in the
Appendix, No. 93], a tubercle grows on the base from the lower
commissural layer of the pons, whereby the pyramidal strands
are pushed so gently aside that no trace of any signs of
pressure are set up around, and, nevertheless, neuro-retinitis
is present, there is then scarcely any sense in which we can
pretend that pressure has been exerted upon the vessels of the
eye. Still less probable is this mechanical theory in the case
of small tumours of the cerebellum. Besides, there are other
things also against this theory. Therapeutic experience has
taught us that such neuro-retinitis can be entirely reduced
without any diminution in the size of the tumour (/3). More-
over, the neuro-retinitis, as we know from clinical observation,
very often sets in stormily with symptoms of irritation, espe-
cially with headache (y). And it is hard to see why the con-
gestive phenomena either primarily, or indirectly by means of
exudation into the brain, should set up mechanical hindrance
in no other circulation, and should set up pressure upon no
other nerve district than that only of the eye (8). Thus the
mechanical theory suffices for certain cases only (e).

( There is the further notion, that in cerebral affections the
neuro-retinitis is due to a neuritis descendens. This view
explains certain cases only. Were the neuro-retinitis due as a
rule to the propagation of inflammation downwards, then the
disturbance in function ought frequently to come on without
any pathological appearances in the disks. The pathological
process at any single part of the nerve bundle ought as a rule
to produce disturbance of function before the process has
reached the periphery, and this the more, as it must be more
active at its starting-point than at a part secondarily affected.
A neuritis descendens can then only be admitted if the am-
blyopia sets in without ophthalmoscopic appearances, and the
changes in the disks show themselves by little and little ()
Moreover, on this view all cases would be unexplained in which
the progress of the inflammation on to the course of the optic
nerves cannot be proved, in which, that is, the original affec-

v.] INTRACRANIAL DISORDERS. 121

tion does not lie in their course (r/). In the third place, the
neuro-retinitis and the functional disturbance often come on
quite suddenly, and frequently like a shock, which most cer-
tainly cannot be reconciled with an anatomical process pro-
pagated by continuity (0). Fourthly, in the majority of cases
the original process is neither an inflammation, nor does it
set up inflammation in its neighbourhood ; and if we are not
to interpret the neuro-retinitis as inflammation in the old
sense, but as hypersemia, with swelling and subsequent growth
of the interstitial tissue, yet if neuro-retinitis is understood to
be a propagated anatomical process, this process must be
demonstrated in complete continuity from the immediate
neighbourhood of the original affection up to the disks, which
in many cases at least is not possible (t). Secondary atrophy,
both ascending and descending, appears in many cases, and we
do not accurately know the conditions under which it occurs ;
but, for the above-named reasons, the neuro-retinitis, in the
greater number of cerebral and cerebellar affections, cannot be
regarded as neuritis descendens.

' Now in order to know how cerebral processes, whether
they encroach upon the course of the optic fibres or not, or
whether they are bilateral or not, influence the optic nerve
by trophic changes, we must consider those processes in
general which in local diseases of the brain take place in its
other parts ; and, above all, we must enquire whether slow-
growing local diseases in the brain are to be regarded as local
trophic processes, as on the answering of this question hangs
the proper understanding of most cases of neuro-retinitis
symptornatica. We see, for example, in the development of
cerebral tumours, that at certain periods, periods which ap-
parently correspond to those of more rapid growth, widespread
symptoms appear ; headaches before all, which are variously
localised, and may attain a degree of severity which deprives
the patient of consciousness; then dizziness, sundry pareses
and palsies, singing of the ears, and finally, amblyopia and
amaurosis. In other cases the symptoms advance less boister-
ously, but are more abiding. These symptoms may then
subside again for longer periods and the patients seem well.

122 OPHTHALMOSCOPE IN [CHAP.

What is the anatomical process which calls forth these phe-
nomena in remote parts of the brain ? Apparently not direct
irritation of the tumour upon its own environs, for a number
of these symptoms are wholly independent of the site of the
disease. The ophthalmoscope teaches us rather that these
symptoms depend upon hypersemia with swelling- (*).

' On the other hand, we frequently see especially in athe-
roma of the cerebral arteries such vascular storms (Gefass-
stiirme) arise, which lead to the sudden onset of unconsciousness,
hemiplegia, paraplegia, &c., and quickly pass off again, and a
few autopsies made soon after point out that attacks of this
kind need no permanent pathological process for their oc-
currence, but that hypersemia with swelling suffices to induce
them, and that these vascular storms depend at one time upon
hypereemia alone, at another upon hsemorrhage also, &c. (A).

* That in acute local diseases, as in cerebritis, the circulatory
changes are still less local in distribution, scarcely needs to be
explained.

4 Thus we see that localised intracranial diseases set in with
vasomotor disturbances which affect the whole or a great part
and remote districts of the brain, and, among other things,
neuro-retinitis appears as a sign of this vasomotor excitement.

* No one will look upon this widespread vasomotor disturb-
ance as a diffuse irritation of particular vessels; in local
affections within the skull we have rather to deal with coin-
cident or preceding neuroses of the sympathetic fibres, with
a local fever, as it were. Symptomatic neuro-retinitis thus, in
most cases, depends upon a morbid innervation of the sym-
pathetic, which again is a symptom of manifold cerebral
processes.

' We now thoroughly understand how it is that we find a
morbid sensitiveness of the sympathetic in most cases of brain
affection which have once become chronic.

' It is now come nearer to our understanding also how it is
that with tumour of the pons an affection of the cortical sub-
stance may come on which leads to dementia ; further, how
the most various affections of the brain in all sorts of places
produce pain in the districts of sensory nerves, how suddenly

v.] INTRACRANIAL DISORDERS. 123

palsy of the respiration or of the circulation sets in, how
hydrocephalus also is established in those cases where there
can be no notion of a creeping of the process onward by con-
tinuity to the lining of the ventricles.

1 All these processes depend upon sympathetic vasomotor
disturbances, which in certain particular places, for instance, in
the lining of the ventricles and in the optic nerves, have a
special tendency to become chronic and to beget secondary
trophic disturbances (/ut). In the case of the disks this special
disposition is explained by the passage of the vessels of the
retina through the rigid fibrous capsule of the sclerotic. If
now a strong and active hypersemia with swellings sets in, the
ebb of the blood is prevented, and stoppage occurs, which is at
first manifest in dilatation of vessels and growth of connective
tissue, and subsequently in the atrophy of the vessels and of
the nerve tissue consequent upon the swelling of the con-
nective tissue.'

Benedikt then goes on to argue from his own clinical ex-
perience, that the control of the optic nerves by the sympa-
thetic is proved by the therapeutic success which follows the
galvanisation of the sympathetic in neuro-retinitis ; into this
part of his argument I cannot now enter. I have translated
these pages word for word, because the views here urged by
this able physician are not only very important to the matter
in hand, but have bearings both clinical and pathological of
the widest interest. In order to discuss them with the care
they require, I have lettered the important points, so that
I may omit none, and may make references without repe-
titions.

Benedikt has not, in the first place, quite comprehended
the meaning of those observers who attribute the papillary
changes to intracranial pressure. Although pressure directly
or indirectly applied in the course of the ebb of the circula-
tion (a) will set up these changes, yet the agent in many cases
is not mere local pressure, but a general elevation of intra-
cranial tension due to an excess of its contents. The ex-
quisitely packed and mobile contents of the cranium are
almost as sensitive to increase of tension as a dense fluid,

124 OPHTHALMOSCOPE IN [CHAP.

so that an excessive growth at any part, however remote,
increases the tension in many directions, and in directions
which tend to resolve themselves towards the sinuses and
towards the base where lie the cavernous sinuses. In con-
sidering* this effect of tumours we have, however, to take more
carefully into consideration the rate of the growth of them.
It may well be that ' optic neuritis' disappears in the course
of a case when the tumour is not decreasing in size (/3).
I think this is not common, but I have seen something like
it in more than one instance. It is quite conceivable that
the parts may find some new accommodation which is too
subtle for plain description ; but it is also certain that the
growth of a tumour is attended with destructive effects which
might soon compensate the encroachment of the tumour itself.
Large strands, cut off from their centres, fall into atrophy, as
the records of numerous autopsies inform us ; and much en-
cephalic tissue falls away from the immediate environs of the
tumour, which might soon relieve the increase of encephalic
tension. In all this the rate of growth of the tumour must
go for much. A rapidly-growing tumour would compress the
surrounding tissues and greatly increase tension, which would
become specially manifest in the disks on account of the
multiplying action of the sclerotic ring (5) ; while a slowly-
growing tumour would rather suppress the surrounding tis-
sues, cut off their nutrition, and separate them from their
connections ; making thus a bed for itself at the cost of
tissues not displaced but abolished. Rapidly-growing tumours,
or tissues of more rapid growth in sluggish tumours, would
thus appear to be attended with ' storms' which cannot be
properly expressed as symptoms of irritation ; not, that is, in
the commonly accepted sense of the word * Reiz.' Headache,
for instance, which is mentioned by Benedikt as a chief instance
of ' reizung,' may be caused quite as well or better by stretch-
ing of the membranes or tentorium (y), and by pressure upon
other sensitive parts. This view seems to me better to ex-
plain the great frequency of headaches in cases of intracranial
tumour than the vasomotor hypothesis, according to which
headache should occur with equal frequency in ' atheroma of

v.] INTRACRANIAL DISORDERS. 125

the cerebral arteries/ in acute softening (A), and many other
diseases.

That the mechanical hypothesis suffices for certain cases
only (e) is very true, but if proven for some cases there is
a presumption in favour of its probability in others where the
phenomena are identical. The vasomotor hypothesis, on the
other hand, is proven for no particular case, however probable
it may be for all. The advocates of the mechanical hypothesis
do not, however, wish to have it said that this hypothesis
suffices for all cases. They say that intracranial affections
are accompanied sometimes by a peculiar swollen and cede-
matous state of the disks (Stauungs-papilla?), sometimes by a
neuro-retinitis which presents interstitial inflammation of the
disk and neighbouring- retina with less swelling; they con-
tend that these two conditions may in many cases be dis-
tinguished at once, that in many others a little care and
practice will lead to the distinction, and that in all cases the
distinction exists, whether evident or not. They contend
further, that no one can adequately discuss the question
who does not bear this fundamental distinction always in
mind, for they say that the effects being different the causes
must likewise be different, and that no single hypothesis,
whether vasomotor or other, will serve for both results. Eene-
dikt, though not unaware of the distinction, does not keep
it before him, and he speaks as if descending neuritis was
a defence to fall back upon when the mechanical theory was
stormed, rather than a separate fortress, having a garrison of
its own. Whether the neuritis does descend or does not (f),
one thing is certain enough, namely, that in the one class of
cases th& disk alone is affected, and in the other class of cases
the length of the optic nerve is in a state of active hyperamia
with cell proliferation. This has been shown repeatedly in
autopsies not only by myself, but also by Mr. Hulke in Eng-
land, and oftener still in Germany by such men as Virchow,
Schweigger, Samisch, Horner, Liebreich, and many others.
Relying upon the vasomotor theory, however, as adequate
to explain both sets of events, Benedikt is the more ready
to demolish not only the Stauungs-papilla but neuritis de-

126 OPHTHALMOSCOPE IN [CHAP.

scendens also. It is difficult to understand the inconsistency
which makes him roundly assert on page 250, that ' frequently
extreme neuro-retinitis progresses for a long time without
any disturbance of vision whatever (" ohne irgend welche
Sehstorung "), or with a disturbance so slight that the patient
does not draw attention to it ;' and argue; on the other hand,
that there can be no neuro-retinitis, even in a short length of
the nerve within the skull, without disturbance of the visual
function. Surely if vision coexists with the inflammation of
optic nerves in their whole lengths, it may well escape when
lesser lengths are involved. Moreover, this argument cuts
both ways, for the nerve conduction, if affected by a known pa-
thological change at all, must still be affected by that change,
however induced. As a matter of fact, clinical experience and
microscopical investigation have led me to believe that severe
neuritis may, and often does, exist in the optic nerve without
destroying the continuity or the conducting power of the
fibres. The mischief rages around them, and although the
pressure of new products may compress the fibres and disturb
them if these products be in great quantity, yet, generally
speaking, their quantity is not so great, and the fibres keep
their way unbroken. Thus the mischief descends, and be-
comes neuritis of the disks before sight is affected. Here,
however, a new condition comes into play. The neuritis now
becomes neuro-retinitis, a belt of retina of more or less size
is involved and its transparency lessened, while over a larger
portion still we may note an excess of venous blood and a
tendency to cedema, which must seriously interfere not only
with the transmission of light, but also with the function of
that most delicate structure. We do now often find some loss
of vision, be it more or less, we see how it is that its descent
from the encephalon may be unperceived, and also why it tends
to break up vision as soon as it interferes with the end organ.
That neuritis is seen in many cases in which the central
irritation is not in the course of the optic fibres (77) is no
doubt true, but it cannot be too carefully remembered that
neuritis is not so much a disease of nerve as of nerve invest-
ment, and that it would be hard to say when the central

v.] INTRACRANIAL DISORDERS. 127

irritation is remote from that framework of delicate con-
nective tissue which carries the optic nerves, and other en-
cephalic nerve masses, in one scaffolding. The cause of the
sudden onset of blindness in some cases of neuritis (0) is as
yet unknown, or known but obscurely ; it seems to me, how-
ever, that inflammation may attack the nerve and retina as
suddenly as it may attack a lung 1 or a peritoneum, which are
a thousandfold greater. The fourth objection, that neuro-
retinitis so often occurs in connection with a non-inflammatory
intracranial disease (i), carries no more weight than the ob-
jections which have preceded it. Here we need the ex-
perience of one actually practised in the use of the mirror, and
who will keep us closely to the distinction between ischaemia
papillae the signal of intracranial tension and neuritis, the
signal of intracranial irritation. Is it the fact that neuritis,
properly so called, does coexist so frequently with non-inflam-
matory intracranial disease ? I here join issue, and declare
that it does not, but that non-inflammatory disease with
increase of bulk gives rise rather to the choked disk (ischemia) ;
while, on the other hand, primary neuro-retinitis rather ac-
companies disease, not necessarily attended with great increase
of bulk, but certainly attended with irritative proliferations,
such as syphilitic meningo-cerebritis. That the curious
periodicity of the other symptoms of nerve disturbance is due
to vascular storms (K A) seems to me not only unproven but of
little value if true, for if we have still to ask the reason of the
periodicity of the vascular storms, we seem to be no nearer the
explanation we desire. If we explain the periodicity of nervous
symptoms by assuming that nerve growth, or accumulation of
nerve force, consists in the building up of highly complex mole-
cules, which molecules in the normal state have a relative sta-
bility, but which in the diseased state have a relative instability,
we see, though in a glass darkly, how it is that the nutrition
of the unstable parts only reaches a certain elevation, at which
the parts then collapse with release of energy. The greater
the instability, the sooner this degree is reached, the more
frequent the resolution of the molecules, and the less the
force released ; all of which fits in well with our clinical

128 OPHTHALMOSCOPE IN [CHAP.

experience of deferred and violent convulsion as compared
with repeated and diminished convulsion, the latter signifying 1
worse things than the former. On the other hand, to explain
nerve instability by vascular instability, which vascular in-
stability must be referred back again, I suppose, to nerve
instability, leaves us where the native was left who proposed
to escape from the bear by running up a tree and then pulling
up the tree after him. In spite of our ingenuity, we find the
dilemma remains as unavoidable as ever. The remainder of
the quotation from Benedikt (/u) contains little more than a
dogmatic reassertion of his position. He points out, that as
local intracranial disease is attended by disturbances of remote
parts of the encephalon which are due (may be due ?) to
the intermediation of vasomotor fibres, neuro-retinitis is
therefore due likewise to vasomotor irritation. All this is the
proof of incertum per incertius. That dementia commonly
accompanies, tumours of the ppns, and is therefore due to
vasomotor irritation taking effect in the grey matter of the
hemispheres, may^be the case ; at any rate, I am not concerned
to deny it. But I must protest against his assumption that
hydrocephalus has any such causation. The explanation I
have given (p. 159) of the concurrence of secondary hydro-
cephalus with intracranial tumour is assuredly the true one,
and the ventricular dropsy which follows tumour is no more
due to vasomotor changes than is the ascites which follows
cirrhosis of the liver. As a matter of private opinion, I believe
that the secondary affections which follow intracranial
tumour are due to many causes, chiefly to distension of
fibrous structures, to narrowing or degeneration of arteries,
and to direct irritation of nerve nuclei, cells, or fibres.
Finally, I would enquire what Benedikt means by 'active
hypersemia' (' eine starke active hyperamie ') ? (/u). By an
active hypersemia I should mean an arterial dilatation flush-
ing the fundus with bright blood, as we see in some cases of
retinal congestion from exposure to bright light and the like.
Such a hypersemia may well be attributed to vascular palsy,
and to vascular palsy it is probably due in the cases to which
I allude, but I have never seen such a state as this in any

v.] INTRACRANIAL DISORDERS. 129

mode of ischaemia papillae or of neuro-retinitis, and I am
tempted to presume so far as to deny its occurrence.

Such are my objections to Benedikt's explanation of the
symptomatic changes in the eye; let me now sum up the
arguments for my own side. First of all, let it not be for-
gotten that, putting atrophy on one side, we have to deal
with two kinds of secondary change in the disks : the one is
a choking of the disk itself, the nerve and the retina remain-
ing unaffected or nearly so ; the other is a hyperamia with
active cell proliferation in the length of the nerve. These
two kinds of change have been distinguished over and over
again in autopsies, and they are generally to be distinguished
during life. In cases which are watched throughout, they are
perhaps always to be distinguished ; but in the later stages of
the choked disk, when the long congestion has impaired
nutrition, set up intimate lesions, and favoured cell prolifera-
tion, when, in a word, the choked disk has become papillary
neuritis, then the distinction which really exists may be in-
visible to the mirror, and after death more or less of the nerve
length may turn out to be involved in the mischief. Still the
distinction always remains to the reason, even in cases like
that published by Mr. Hulke in the second part of the sixth
volume of the * Ophthalmic Hospital Reports,' where on the
autopsy the choked disk was found, and a descending neuritis
also found, which was on its way to the eye. I have described
a like case (p. 90), which I examined after death. Now, when
we enquire into the association of optic changes with cases of
intracranial disease, we find that a large class of them, such, for
instance, as encephalic softenings, are not accompanied as a rule
by any optic changes at all, although in such cases we have
symptoms of wide disturbance, and vasomotor centres or fibres
are as likely to be involved as in any other. Nor, again, do
we find that tumours in the optic thalami (away from the
optic tracts) in the crura and in the pons, which, according to
Schiff, contain many sympathetic fibres, are more commonly
accompanied with optic signs than tumours elsewhere, but
rather the contrary. But we do find optic changes in con-
nection with two kinds of intracranial disease in particular ;

K

130 OPHTHALMOSCOPE IN [CHAP.

the one is tumour, the other is meningitis. Again, when we
analyse the matter one degree farther, we ascertain that al-
though the choked disk and the inflamed nerve may coexist
with either of these kinds of disease, that, nevertheless, the
choked disk is far more commonly found in association with
tumour and hydrocephalus than the inflamed nerve. The
inflamed nerve, on the other hand, is very commonly found in
association with meningitis, and with meningitis, not of the
surface nor of parts near any supposed vasomotor centres, but
with meningitis near the chiasma. Moreover, it is found to
have a special affection for that particular kind of meningitis
which forms a part of the syphilitic series, which loves to crawl
about the fossae at the base of the cranium, and which is
marked by a peculiarly active proliferation of unstable cells.
If now we compare the process of choking the disk with the
process of inflaming the nerve, we see that hypersemia, not
* active' but passive, helped by that multiplying action of the
sclerotic ring, which Benedikt also calls to his aid, is adequate
to produce the former, while the phenomena of the latter
point rather to a biological process of cell proliferation due to
propagated irritation. The adequacy of pressure to produce
the choked disk is well illustrated by the prominence of the
eyeball, not infrequently caused by intracranial tumours,
by the ophthalmic symptoms of orbital tumours which often
cause swelling and opacity of the disk, and again by the
recent experiments of Professor Manz 20 . By injecting fluid
into the cranial cavity of rabbits, he was able at once
by the increased pressure to set up dilatation and curvature
of the retinal veins with stasis. When we see, then, that
pressure is a competent cause of choking of the disk, and
when we see, moreover, that the choked disk is commonly
found with that particular kind of intracranial or intra-

20 'Centralbl. d. Med. Wissensch.' Feb. 10, 1870. Compare also a remark-
able case of plugging of the ophthalmic vein with consequent venous distension
of the orbit, published by Mr. Hulke, 'R. O. H. Kepts.' No. VII. 1859, and
a like case published by the late Mr. Nunneley of Leeds (' Path. Trans.' vol. xi.) :
where the same results were found to be due to an aneurism of the internal
carotid pressing upon the cavernous sinus.

v.] INTRAGRANIAL DISORDERS. 131

orbital mischief which increases pressure, are we not justified
in requiring very strong evidence before we admit that its
causation is quite otherwise ? Again, when we know from
many preparations in our museums and from clinical ex-
perience, that inflammation does tend to run along the course
of nerves, as in certain familiar cases of wounds, of contrac-
tions of the limbs, intense neuralgias, &c., and when we find
such a process as this in the optic nerves, and see that it is
likewise attended with the pain due to stretching of its dense
sheath, when we see this proliferation also in the third, sixth,
or other nerves, not uniformly but according to the acci-
dental disposition of the central mischief, when, again, we
find this inflammation of the connective tissue of facial nerves
commonly associated with the very similar or identical in-
flammation of the fibrous structures in the immediate neigh-
bourhood of the nerves, either within the orbit or within
the cranium, is not the inference almost irresistible that the
neuritis is an offshoot of the meningitis, especially when we
discover further, that when this optic or other neuritis, rather
than ischsemia papillae, is associated with tumour, an inter-
mediate term exists in the form of a basilar meningitis set up
around the tumour? Such cases are numerous, and very
difficult to set aside. When, on the other hand, we look
at the arguments against us, when we find them resting in
great measure upon conjecture, or upon such observations as
those of Adamiik, which, however valuable in their bearing
upon iridectomy, glaucoma, and the like, seem to bear little
upon neuritis and ischsemia; when we find, moreover, that
whatever is really known of implication of the sympathetic is
against its action in the way supposed ; when, for instance, in
cases of diseased cervical sympathetic, or of diseased trigeminal
ganglion, we find its implication threatens or destroys the coats
of the eye without any special implication of the optic disks ;
when, again, we see in symptomatic affections of the disks that
two distinct morbid events need a duality of causation ; when,
finally, we see in disks so affected that no rosy blush suffuses
the nerve and retina, as in the cases of so-called active hyper-
semia, but rather a slow, accumulating venous stasis tending

K 2

132 OPHTHALMOSCOPE AV [CHAP.

to proliferation ; when we see these weaknesses of the vase-
motor hypothesis, we must surely hesitate before we relinquish
those older hypotheses which seem to be satisfactory.

For the purposes of this volume, then, I shall still assume
that there is such a thing as descending neuritis, and that it
is due to propagation of irritation, using that word in the
sense in which it is used by the Berlin school. Secondly,
that there is also such a thing as choked disk, Stauungs-
papilla, or ischsemia papilla?, to be distinguished from primary
neuritis, and to be attributed to increased intracranial tension.
I believe these two hypotheses explain more facts than any
others, and therefore are the best to work with at present.
At the same time, I cannot conceal from myself their diffi-
culties, difficulties which I am not altogether able to remove.
These difficulties apply more particularly to the occurrence
of neuro-retinitis in connection with tumours, though some
questions might arise in respect of the causation of the choked
disk also. To take the latter first, it may be objected that, as
in the case adduced by Benedikt, and quoted by me in the
Appendix (No. 93), a very small tumour remotely situated
could scarcely so increase intracranial tension as to interfere
with the ebb of venous blood. I would take leave to point
out here, however, the very fragmentary and partial state
of our knowledge. Benedikt speaks of the optic symptom
as c neuro-retinitis ;' but Dr. BydeFs description, although
he too speaks of ' neuro-retinitis,' is nevertheless suggestive
to me rather of the choked disk, and when I look at the
post-mortem signs, I do not find them to be unlikely com-
panions of the choked disk. But a preliminary difficulty
meets me in this, that I am rather disposed to think the
growth of the tumour was subsequent to the disappearance
of the optic changes, which themselves may have been due
to some other cause. If not, its site is such as to lead me
to think it probable that it might have pressed upon the
great veins of Galen, or upon the lateral or straight sinuses,
and thus induced dropsy of the third ventricle, with pressure
on the chiasma or cavernous sinuses ; or it may have closed
up the foramen of the fourth ventricle, and thus caused ven-

v.] INTRAGRANTAL DISORDERS. 133

tricular dropsy by blocking- the outlet. The state of the third
ventricle is not described, but the lateral ventricles contained
half an ounce of serum, and their lining was thickened in a
way which is suggestive of past effusions.

Unless,, then, the advocates of the vasomotor hypothesis are
prepared with cases which bear examination better than this
one, their arguments must fail. Our examination of this case
is one more instance of the impossibility of reasoning on this
subject, unless minute care be taken to distinguish between
the choked disk and neuro-retinitis, a distinction which may
be difficult or impossible during life, but which is always
possible after death 21 .

It is less easy to explain the connection of neuro-retinitis
with tumours. To those who are satisfied with such an
explanation as this, that the inflammation of the nerve tissue
is due to the irritation of a 'foreign body/ I need say no
more ; but this does not satisfy me, and I fear some of my
readers will likewise see a gap in this comfortable reasoning.
As a matter of fact, I must admit that I have not found
cerebritis around the few embedded tumours which I have
been able to examine from this point of view. I believe
that tumours as a rule do not set up cerebritis to any
marked degree. A little fibrous thickening or capsulation
immediately around them there may be, but not any actively
proliferating process extending widely through the brain
matter 22 . I have found nothing of this in my own expe-
rience, but only the usual products of demolition. At the same
time, it is equally true that in these particular cases I did not
meet with neuro-retinitis, so that if I have not discovered
the mode in which neuro-retinitis might have been caused,
at any rate I have not plunged any more deeply into diffi-

21 After opening the head, the intraorbital portion of the optic nerve and the
disk may be easily obtained by raising up the orbital plate. No disfigurement
of the eye need follow this operation, if carefully done.

22 Dr. Maudsley says, in his 'Physiology and Pathology of Mind,' p. 388,
' If there is one thing which pathological observation plainly teaches, it is the
slight irritability of the adult brain. The gradual growth of the tumour allows
the brain to accommodate itself to the new conditions, and a closely adjacent
nervous centre may be entirely undisturbed in function until the morbid action
actually encroaches upon it.'

134 OPHTHALMOSCOPE IN [CHAP.

culties. On the contrary, these negative instances seem to
support the opinion I hold on clinical grounds, that genuine
neuro-retinitis is rare in cases of uncomplicated tumour, and
that the optic change which tumours induce is rather ischsemia
papillae. One case only of neuro-retinitis where there was
a wide lilac-grey patch of inflammation embedding the ves-
sels and involving the deep layers of the retina, but without
steep protrusion I have seen in connection with intracranial
tumour, and in this case the tumours (Appendix, No. 81) were
situated in the anterior fossa, and the membranes of the base
were inflamed and thickened in the pituitary region in such a
way as readily to explain the descent of such a process to the
eye, which we also verified. Grafe, who has accurately and
minutely studied this matter from the present point of view,
refers true neuro-retinitis unhesitatingly to meningo-cerebritis.
His words are so important, and I had almost said so con-
clusive, coming as they do from so cautious and so successful
an observer, that it seems desirable to give his words in full, as
they appear in his well-known memoir on the subject published
in 1866 in the ' Archiv. fur Ophthalmologie,' vol. xii. part 2,
p. 114. After saying that neuro-retinitis rarely appears idio-
pathically (comp. p. 74), but rather as a consequence of orbitar
or intracranial affections (organic or circulatory), he refers
briefly to his former distinction, made in the seventh volume
of the same journal, between the neuritis which is confined to
the disk, and 'marked especially by venous stasis in the
papilla, that is to say, by an intense redness, a steep pro-
minence, and often also by haemorrhages,' and the other form
of neuritis, ' in which the swelling and the redness of the disk
are less intense, whilst the opacity of the tissue is more pro-
nounced, more extensive, and propagated more deeply from
the internal layers of the retina to the middle and outer coats/
This latter form he refers to descending neuritis, and this sup-
position of propagated irritation passing along nervous tracts
is so important, and has so direct a bearing upon the progress
of intracranial mischief of many kinds, that I have deemed it
necessary to dilate more at length upon the arguments for and
against it than may at first seem desirable to the reader.

v.] INTRAGRANIAL DISORDERS. 135

The following passage, however, I must translate from Grafe
word for word : ' The supposition which I then made known
concerning the existence of these two different types, is in fact
confirmed. In the first place, I have had the opportunity on
several occasions to make autopsies in cases of the choked disks
("Stauungs- papillae "). I found in almost all the cases intra-
cranial or orbitar tumours. The neuritis was strictly limited
by the cribriform plate, and the changes corresponded so
exactly to the- results published at the time 23 , that I need
not give any detailed account of them. On the other hand, I
have only had three opportunities of examining the other form,
and each time I recognised at the autopsy the descending
neuritis diagnosed during life. I have already spoken briefly
of the first of these cases at a meeting of the Ophthalmic
Society of Heidelberg 24 , but as the two other cases intimately
resemble it, I will return to it in a few words.

' During life there were vague and ill-defined symptoms,
pointing to an organic affection of the encephalon, but not
allowing of any exact diagnosis. We were, however, in a
position to say that a violent encephalo-meningitic irritation
was present (symptomatic of a tumour?). Some months
before death, a progressive amaurosis declared itself. The
mirror showed the slight prominence of the disk, its dis-
colouration, its greyish aspect lightly tinted with red, and,
moreover, a diffused opacity* of its tissue which extended five
millimetres upon the adjacent retina, and then gradually died
out beyond. There were also some small haemorrhages near
the disk, the arteries were diminished, the venous trunks,
partly hidden by the opacity of the tissue, were thickened
and tortuous; but there was no trace of that extraordinary
development of their minuter branches, of that intense red-
ness and that prominent swelling which characterises the
choked disk. I diagnosed a descending neuritis, and I
inferred the presence of inflammatory centres in the brain

23 That is in the former essay, quoted in ' Archiv. f. Ophthal.' vol. vii. Cf.
et Koster, 'Jahresb. d. niederlandischen Augenhospitals' (1865), pp. 8-18, on
a remarkable case of echinococcus cerebri.

24 Reported in Zehender's 'Klinischen Monatsblattern' (1864), P- 73-

136 OPHTHALMOSCOPE IN [CHAP.

and membranes without marking out their position, but I
decided against the supposition of an excessive increase of
intracranial pressure. The autopsy showed that the cause
of the malady was the presence of certain entozoa (Virchow
reported that they were not echinococci, as we first thought,
but rather resembling csenuri 25 ), which had set up a basilar
meningitis extending to the optic nerves. The anatomical
symptoms suggestive of decided and prolonged augmentation
of intracranial pressure were absent. The following is the
microscopical report of Professor Virchow :

' The prominent portion shows a considerable thickening of
the limitary membrane, and also a swelling of the end of the
optic nerve, in which are large vessels with thickened walls,
between which is a very dense fibrous tissue. The calibre of
the vessels bears no relation to their size, and in many places
their canal is rather contracted ; the thickening is due chiefly
to the adventitia, which is changed into a compact and almost
homogeneous mass. The fibrous elements alluded to, at first
sight give the impression of fibres of connective tissue, but on
tearing the preparation it is evident that they are altered
optic nerve fibres. Most of them are thicker than natural,
many are varicose, and present fusiform prolongations of
moderate size. This alteration is found also in a portion
of the expansion of the optic nerve, but the degeneration
of the vessels is limited almost exactly to the disk. There is
no proliferation of cells or of nuclei in the interstitial tissue ;
but this is visible behind the cribriform plate, where indeed
the neurilemma of the optic nerves is full of nuclei and of
new cells. There is also a peculiar change extending to the
middle layers of the retina near the disk. We find there the
granules of the two granular layers excessively large and
pressed together ; the intergranular layer presents thick stria-
tions, which are perpendicular to the surface of the retina;
and farther, on tearing the microscopical preparation with
needles, a number of fine but tough fibres, provided with
fusiform and varicose prolongations, are teased out from the

25 I may draw attention to this statement, as Reynolds and Bastian (' Reyn.
System,' vol. ii. p. 497) doubt the occurrence of csenurus in the encephalon.

v.] INTRACRANIAL DISORDERS. 137

entire thickness of this layer. In many places there is pig-
ment in the external granular layer.

( The optic nerve in the whole of its length presents a very
considerable thickening of the neurilemma, which is separated
from the surface of the optic nerve by a cystoid mass, and
which only envelopes it as a detached covering. Besides this
" perineuritis," there are the well-marked changes of "inter-
stitial neuritis " throughout the whole length of the optic
nerves. In a word, the result of this examination may be
summed up in the two latter morbid states (perineuritis and
interstitial neuritis in the length of the nerve), and hyper-
trophy with sclerosis of the vessels of the disk.

* In the second case, in which I had also diagnosed a
descending neuritis, the autopsy was not made until long
after the outset of the malady, when a marked atrophy of
the disks had set in. We found a very extensive meningitis
at the base of the skull, set up by a circumscribed tumour,
a meningitis which had directly attacked the optic nerve
trunks. The nerves were diminished in size, their neuri-
lemma thickened, and the nervous tubules were in great
part indistinguishable. There were unquestionable traces
of interstitial neuritis.

' The third case a patient who died in the wards of Pro-
fessor Griesinger presented (according to the report of
Dr. Heine) a circumscribed ramollissement of the left corpus
stria turn, in addition to a very extensive meningitis of the
base of the skull, and a very well-marked descending peri-
neuritis, accompanied by an interstitial neuritis of the optic
nerves. These observations have in every case proved that
there is a neuritis which propagates itself along the trunks
of the optic nerves up to the disks ; the result of the autopsies
and the march of the symptoms allow of no doubt that this
neuritis follows a descending course, and that it is an offshoot
of the encephalitis and of the meningitis.'

Such are the thorough and complete observations of Grafe
and Virchow, and the reader may be referred also for corroba-
tive evidence to the communications of Homer in the ' Klini-
schen Monatsblattern fur Augenheilkunde' (1863), pp. 71-78,

138 OPHTHALMOSCOPE IN [CHAP.

of Fischer in the same for 1866,, pp. 164-169, and of Hutch-
inson in the ' Ophthalmic Hospital Reports/ vol. v. part i ,
p. 107. These are the facts and arguments upon which I
found my opinion that neuro-retinitis, or neuritis descendens,
is due to meningitis either primary or secondary, or in rare
cases to encephalitis, and that ischsemia papillae is due to
increase of intracranial tension or to some special interference,
such as direct pressure or thrombosis, with the circulation in
the cavernous or the petrosal sinuses.

Atrophy of the optic nerve, not consequent upon neuritis,
but primary, is a third form of mischief found in connection
with intracranial tumour. My own opinion is that primary
atrophy results for the most part from the crushing or dividing
action of tumours of the base, which sever the nerves from
their central connections, from pressure of hydrocephalus upon
the optic nerves, tracts or centres, from direct implication
in the softening which remoter tumours set up around them-
selves, or sometimes from propagation of a sclerosis. It is
possible, however, that atrophy may also be set up by tumours
pressing upon distant but related strands or centres, and so
causing optic atrophy indirectly. Lancer eaux 2G holds this
view veiy strongly, and makes out a good case by careful
study of instances in which secondary atrophy of several
great strands, including the optic nerves, followed central
lesions. The labours of Schrceder van der Kolk and Tiirck 27
on this subject are well known, and of great interest.
Charcot and Vulpian have also published very interesting
observations of the same kind, and it may be taken as proved
that secondary atrophy of the motor strands of the pons,
medulla and cord do follow serious lesions, such as softenings
and tumours, of the motor centres. The principle upon which
these changes are to be explained, was laid down by Waller

26 See his essay upon Amaurosis, 'Arch. Gen. de la MeMecine,' Jan. and
Feb. 1864.

27 Schroeder van der Kolk's work originally appeared in Dutch, and found
its way into several English journals. Tiirck's principal essay is entitled
'Ueber secund. Erkrank. ein^elner Riickenmarkstrange,' Wien, 1851. Gubler
has dealt with the subject in a good article in the ' Archives de Me'decine '
(1859), v l-

v.] INTRACRANIAL DISORDERS. 139

many years ago, who first demonstrated the atrophy which
results from the severance of nerve fibres from their central
connections 28 . M. Lancereaux finds the explanation of the
concurrence of optic atrophy with lesions of the hemispheres,
in Gratiolet's supposition, that the hemispheres are their
actual centre, a supposition which is far from proved. I
must speak with the highest respect for the ingenious and
laborious essay of M. Lancereaux, but, as a matter of clinical
experience, I find that primary atrophy is generally due to
mischief at the base, or to ventricular dropsy, which compress
and sever the nerves or tracts at some point in their direct
course, that is, no higher than the quadrigeminal bodies.
Moreover, the rarity of amaurosis in cerebral softening
compared with its frequency in tumour, and, again, the
appearance of ischsemia rather than atrophy in tumour of
the higher ganglia, seems to me opposed to a belief that
the amaurosis is in these cases a Wallerian atrophy.

Nevertheless, there is evidence to make it very probable that
severance at the base is an efficient if not the common cause
of atrophy. No one has shown more carefully how distinctly
such secondary degeneration resembles the atrophy of amau-
rosis than Dr. H. O. Barth, who in a recent paper has added
much to the labours of Tiirck and Vulpian 29 . Dr. Barth
establishes the truth of the observations of his predecessors,
and points out that the degeneration is not primarily of a
fatty kind, except about the walls of the larger vessels, nor,
again, is it an active nuclear proliferation, but something
between the two. He finds the nerve sheaths beset with
numerous albuminoid granules, and a great increase of very
fine fibres, which make a close network. These seem to be
connected with independent nuclei and with the nuclei of the
capillaries. This is clearly, he says, an increase of the neuroglia.

28 I ought, however, to admit here that Waller believes the retina to be the
trophic centre of the optic nerve, nor is he alone. May not its nutrition
depend upon the reaction between its origin and its end organ ?

29 'Ueber secundare Degeneration des Riickenmarks. Arch. d. Heilkunde,'
s. 433, taf. viii. I may explain here that Vulpian and others have shown that
the 'degeneration of a severed nerve takes place pretty equably throughout the
peripheric portion. This agrees with my experience of optic nerve atrophy.

140 OPHTHALMOSCOPE IN [CHAP.

Let us now see how far these ophthalmoscopic signs, and
the inferences they justify, will help us when we approach
the diagnosis of intracranial tumours in detail 30 . Many symp-
toms must be taken into account if we are to satisfy ourselves
on these points, and although we have to do with the oph-
thalmoscopic symptoms in particular, yet it will help us in
some measure to keep our eye upon some other symptoms
also. I shall now divide the intracranial cavity into certain
arbitrary regions, in order that we may know what symptoms
follow the growth of a tumour in any one of these. Those
divisions which I have found most convenient are as
follows :

(1) Tumours of the convex surface.

(2) whole hemisphere.

(3) anterior lobe.

(4) middle lobe.

(5) posterior lobe.

(6) corpus callosum.

(7) corpus striatum and optic thalamus.

(8) crus cerebri.

(9) cerebellum.
(10) crura cerebelli.

(n) corpora quadrigemina.

(12) pons varolii.

(13) medulla oblongata.

(14) anterior or ethmoi'do-frontal fossa.

(15) >> middle fossa.

(16) posterior or cerebellar fossa.

(17) Miscellaneous intracranial tumours.

The nature of the tumour, cyst, or thickening, cannot, as
I have said, be distinguished by clinical methods ; if in some
cases it may be guessed at, the optic signs would give little
assistance. It would be impossible even to assume, from the
presence of neuritis rather than ischsemia, that the tumour
was of a proliferating or irritative kind, as inflammatory
action may be the result of lesion from pressure, or pressure

30 Intraorbital tumours are left out of the question for the sake of brevity.

v.] INTRACRANIAL DISORDERS. 141

again may be the result of inflammatory accumulations. One
remark, however, I may make on the effects of a certain kind
of tumour, which is, that intracranial aneurisms seem to inter-
fere less with the special senses than do other tumours. This
conviction had forced itself upon my mind in consequence of
an autopsy upon a case in which an aneurism of the internal
carotid, the size of a cherry and close to the chiasma, had not
been attended with ophthalmoscopic signs. I have also seen
one or two such cases recorded by others, and I think it must
have struck most of us that intracranial aneurisms seem to
grow somewhat innocently until their final and terrible catas-
trophe. I am glad, therefore, to find that Ladame distinctly
expresses the same opinion ; he says (p. 29), t aneurisms seldom
give rise to symptoms of irritation.' And again, ' Aneurisms,
whose seat is especially at the base of the skull, have symptoms
which are very analogous with those of tumour in this region.
It is remarkable, however, that they rarely give rise to dis-
turbances of the senses.' The explanation of this peculiarity
lies, I believe, in this, that an intracranial aneurism is far
more elastic and yielding than a tumour. Aneurisms in the
head are often little more than thin walled bags, which pro-
bably vary much in their states of distension and collapse.
The chief exception to this is the tendency of aneurisms of
one anterior cerebral artery to cause amaurosis of the one
corresponding eye, a tendency which is a very important
element in the diagnosis of such cases.

(i) Tumours of the convexity.

It is very difficult to isolate the effects of tumours in this
situation upon the optic nerves. Tumours of the convexity
tend rapidly to destroy the substance of the brain and to
affect the mesocephalon, including the thalami, the corpora
geniculata, and the corpora quadrigemina. Moreover, fungoid
and other tumours springing from the dura mater are very
likely to interfere extensively with the cranial sinuses, and
thus indirectly with the ophthalmic Vein. Granting, there-
fore, that neuritis accompanied a tumour of the convexity, it
would remain doubtful whether the optic change was set up

142

OPHTHALMOSCOPE IN

[CHAP.

by direct interference with the ebb of blood, by destruction
advancing into the mesocephalon, or by the direct effects of
the tumour upon the surface of the hemisphere 31 . The ques-
tion is one of some interest in this way, that the theory urged
by Gratiolet, that optic fibres spread upwards into the hemi-
spheres, and are thus the direct means of cerebral perception
of light, is applied earnestly by Lancereaux to the explana-
tion of symptomatic mischief in the disks. He considers, as
I have said, that irritation or destruction of certain cerebral
attachments of the optic fibres is sufficient to set up secondary
atrophic changes in the nerves and disks. Were this so,
tumours of the convexity would have much interest for the
physiologist as well as for the physician.

As I have said, however, it is very difficult to find a case
of tumour of this seat in which the morbid process does not
extend deeply into the mesocephalon ; so that it is impossible
to say how much of the resulting neuritis is due to the super-
ficial mischief, and how much to the deeper mischief. Ambly-
opia, such as to command the attention of the physician, does
not, as a matter of fact, seem to occur in a large proportion
of cases of tumour of the convexity. I cannot, however, find
ar.y satisfactory case in which the optic nerves were carefully
examined during life or after death. Lebert and Ladame
found affection of vision in a few cases. Their cases were
uncontrolled by the ophthalmoscope ; but a lesion of fibres
stretching up into perceptive ganglia ought to be indicated
very soon by loss of visual function : indeed, loss of visual func-
tion should precede obvious mischief in the disks. Cases of
tumour of the convexity, however, give no encouragement
to the theory that optic fibres pass up directly, and for mere
visual ends, into the hemispheres, if I may rely upon the
cases collected by myself of tumours in this position, which
amount to five-and-twenty in number, and which represent
lesions of every superficial part of the brain 32 . A case is

31 This difficulty is the greater, as in so many records of autopsies these
secondary points are not observed, or but slightly touched upon.

32 I need scarcely remind the reader that it has been shown by numerous
observers, by Voit, Kosenthal, Goltz, and many others, that removal of the
hemispheres in pigeons and other animals is not followed by loss of sight.

v.] INTRACRANIAL DISORDERS. 143

recorded by Thomas Salter in ' Guy's Reports/ vol. vi. 1841,
in which a tuberculous tumour on the surface of the posterior
portion of the right hemisphere was attended with ambly-
opia. Another case, also, I have in my own note-book which
was quoted in several of the journals in 1866. It was first
reported by Fraumiiller. A man, aged 28, suffered from
symptoms of tumour, including headache, vomiting, convul-
sions, &c., and also from loss both of sight and smell. After
death a superficial flat (myxomatous) tumour was found lying
upon the surface of the right hemisphere. Abercrombie quotes
two cases of this kind, both of which were attended with
amaurosis ; but it is to be remarked that in both these cases
the tumour was under the temporal bone, that is to say, near
the base of the skull. In one of them, which Abercrombie
quotes from Wepfer, there was an exostosis of 3" broad
and i" thick on the inner surface of the left temporal bone ;
the symptoms in addition to the amaurosis being great head-
ache and convulsion. In the other case, a gelatinous tumour
of the size of a hen's egg lay also under the left temporal
bone between the pia mater and the arachnoid. There was
blindness, together with convulsion. There was also slight
right hemiplegia, showing that the tumour affected more
than the surface, either by consecutive softening or haemor-
rhage, or both. Rosenthal, in his recent volume on nervous
diseases, relates a case in which he found several (' mehrere ')
tuberculous swellings upon the convexity of the left hemi-
sphere. He mentions among the symptoms convulsion and
aphasia, with some mental deficiencies, but does not mention
any loss of vision. Headache is of course a very common
symptom in tumours, which thus directly involve the mem-
branes, and convulsion occurs with the frequency which we
notice when morbid processes involve the cortical substance.
Mental disturbance is by no means invariable, but undoubtedly
common. I find such disturbances in seven out of seventeen
of Ladame's cases, but I think this proportion is too small,
for I find them in two-thirds of the cases, nine in number,
which I have collected in addition. The relation of amau-
rosis to other symptoms in these rather easily diagnosed

144 OPHTHALMOSCOPE IN [CHAP.

tumours is, then, headache frequent, convulsion frequent,
mental derangement frequent, constipation frequent ; vomiting
seems to be less common than constipation, and amaurosis is
occasional, or in simple cases rare. Like fever and strabis-
mus, it is probably a secondary event, and depends directly
upon extension of meningitis or softening below.

(2) Tumours of a whole hemisphere.

Such tumours might be expected to have only the effects
of tumours of any one of the lobes, or of the three separate
lobes put together ; this indeed may be so, but in the present
state of our knowledge it is well to look at the matter from
every point of view, and to assume nothing. The size and
extent of the tumour has probably effects as important as its
locality. Defect of vision is certainly numerous in tumours
which occupy all three lobes. Both Lebert and Friedreich
found this defect in about two-thirds of their cases, Ladame
in one-half; but Ladame thinks his proportion is probably
too low. When we see that disturbance of vision forced itself
upon the notice of the physician in so large a number of cases,
we may well suppose that a far greater number would have
revealed ophthalmoscopic change. Take, for instance, the
case quoted by Abercrombie from De Blois, where three
tumours were found in the right hemisphere in a boy aged
seven. In this case, although hydrocephalus was also present,
yet no affection of vision is mentioned. The intense headache
probably concealed any dulness of vision which may have ex-
isted, and my experience will scarcely allow me to doubt that
marked changes might have been found by the mirror, not
only in this, but in many other cases, of tumour of equal extent.
The case occurred in 1831, long before the ophthalmoscope
was thought of.

A case is recorded by Powel in the ' Medical and Chirur-
gical Transactions,' vol. v. p. 219, in which weakened vision,
dilated pupils, and finally blindness occurred in a case where
a tumour was found with three other hardened portions (glio-
mata?) in the upper part of the length of the right hemi-
sphere. In some of the similar cases I have collected there

v.] INTRACRANIAL DISORDERS. 145

was hydrocephalus, in others there was none. The careless
way writers have even yet of including the corpora striata and
the optic thalami with the hemispheres, and also of calling
all the nervous centres in the head together the cerebrum
or brain, makes it difficult to be sure, in particular cases,
whether the mischief did or did not penetrate below the ven-
tricles, or set up secondary changes below them. One thing,
however, does seem clear, that while in superficial adven-
titious growths upon the convexity, loss of sight is rarely
present, in tumours which occupy the mass of one hemisphere
affection of the optic disk must rarely be absent. We should
still, of course, expect to find convulsion a common feature
in disease so deeply involving the cortical substance ; while
hemiplegia would be less common, and would occur only
when the mesocephalon was compressed, softened or involved.
Such is the conclusion derived from the cases themselves, the
relation of symptoms being headache very common, con-
vulsion very common, mental deterioration, amaurosis, and
constipation common ; vomiting and hemiplegia not so com-
mon. A young lady whom I saw once or twice with Mr.
Teale presented this array of symptoms with fine choked
disks. After death a tumour was found occupying almost the
whole of the right hemisphere. We diagnosed tumour of the
hemisphere but had nothing to tell us of its extent. Fever
is rarely mentioned, and probably occurs only in company
with meningitis. Other nerves of the base unaffected unless
by extension of meningitis, which seems to have been the
cause of ptosis or strabismus in one or two instances.

I may perhaps remind the reader that recent observers are
disposed to attribute emotions, if there are such things, rather
to the right hemisphere. Certainly I find emotional dis-
turbance to have been more common in disease of the right
brain.

(3) Tumours of the anterior lobes.

Dr. Russell Reynolds, in his < System,' page 483 (ed. 1868),
thinks that ' convulsions are most frequent in tumours of the
cerebellum, and that they diminish in frequency as the seat

L

146 OPHTHALMOSCOPE IN [CHAP.

of lesion advances forwards, i. e. through the posterior and
middle to the anterior lobes of the cerebrum ; and that
amaurosis, impaired articulation (speech?), and intelligence
observe a contrary relation to those lobes, being most common
when the tumour is in the anterior cerebral lobes, and relatively
less frequent as the seat of the tumour retrogrades.' I have
myself only met with the one case of tumour in an anterior
lobe, to which I have already made allusion (App. No. 81);
but I have collected records of thirty-eight well-marked cases.
In nine of these only are dimness or loss of vision noted ; but
of course ophthalmoscopic signs may often have been present
though no loss of vision was observed. Some of these cases
are well reported, and my impression from these well-reported
cases is, that optic signs will be found to occur frequently in
tumour of the anterior lobes. Consecutive mischief soon
reaches the pituitary region, as in my own case, and some-
times the morbid growth penetrates the orbital plates. I have
not included these latter cases, however, as disturbance of the
eye must occur in them as a matter of course ; and they are,
from our present point of view, to be called orbital rather
than encephalic tumours. Dr. Todd described an interesting
case in the * Medical Times' of 1853 ( vo ^ ** P- J 66), where
a large hard tumour in the anterior lobe of the right hemi-
sphere caused convulsion and amaurosis without paralysis.
The optic tracts were softened, and the corpora geniculata
were of an abnormal colour. The optic nerves examined
under the microscope presented numerous oil globules. It
seems a priori very likely that progressive softening surround-
ing tumours of this region should invade the optic tracts
and nerves, and thus cause primary atrophy ; but at present
our ophthalmoscopic evidence is scarcely sufficient to bear
this out. Lancereaux, in the valuable essay to which I have
referred, on ' Amaurosis in connection with degeneration of
the optic nerves in cases of alteration of the cerebral hemi-
spheres,' publishes an admirably described case in which a
serous cyst of the right anterior lobe was found, with atrophy
of the geniculate bodies, optic tracts, left cerebral peduncle,
and pyramid, with the corresponding column of the cord.

v.] INTRAGRANIAL DISORDERS. 147

There was no hydrocephalus. Lancereaux is convinced that
in this case there could not have been any pressure upon the
sinuses at the base. In a second case, recorded with equal
minuteness, a neoplasm the size of a duck's egg was found in
the left anterior lobe coexisting with softening of surrounding
parts, alteration of the optic tracts and nerves, and slight atrophy
of the left cerebral peduncle and pyramid. In this case, how-
ever, there was hydrocephalus, and the corpora quadrigemina
were compressed 33 . The symptoms were headache, dizziness,
convulsions, amaurosis ; no palsy of movement or sensation.
With the mirror Liebreich found the left disk pushed forward
and greyish ; arteries thin and pale ; veins swollen and dark ;
right disk less prominent and white, and falling into atrophy ;
vessels almost lost. Ladame, again, gives an interesting case
recorded by Nolte, ' Med. Zeit. f. Heilk.' No. 38, 1835, in
which ' oscillating amblyopia ' was found to depend upon the
pressure of a distended third ventricle upon the chiasma. The
ventricular dropsy coexisted with a tumour in an anterior lobe
the size of a duck's egg. It is unnecessary for me to add to
this section ; in the vast majority of cases recorded the mirror
was not used ; while, on the other hand, those who used the
mirror record only positive instances. I have said enough,
however, to show that amaurosis does often coincide with
tumours of the anterior lobes, and signs visible with the mirror
occur no doubt, much oftener, as we see from case No. 82 in
the Appendix, where Dr. Jackson found optic neuritis in a
patient who was able to read. After death a tumour was
found in the left anterior lobe. The amaurosis seems to be
due, in some cases to ventricular dropsy, with pressure on the
chiasma, the tracts or the corpora quadrigemina, in which
cases we should probably see atrophy as the first morbid
change in the disks ; in other cases, as in the second of Lance-
reaux, the choked disks were found which were due to pressure
upon the basal sinuses, probably direct. In three cases I find
records of the tumour with the brain matter below it having

83 Such was the case also in an example which I extracted from Vir-
chow's Krank. Geschwiilste/ p. 662-3 ; and in which lessened visual power
coexisted with a tubercular tumour of the right anterior lobe.

L 2

148 OPHTHALMOSCOPE IN [CHAP.

caused atrophy of the optic nerves by direct pressure ; and,
lastly, it seems likely that atrophy of the optic nerves may
result from the extension of softening in their direction, this
softening not being due, I think, to implication of optic fibres
in the hemispheres, as Lancereaux would have it, but to mere
extension by contiguity to the nerves, tracts, or corpora qua-
drigemina, or more frequently to pressure upon their blood-
vessels. I have no evidence that neuro-retinitis occurs in
these cases unless meningitis be present. The summary of
the other symptoms of tumour of the anterior lobes seems to
be headache (frontal or general), mental derangement, con-
vulsions, aphasia (if the mischief be in the left brain), and
anosmia. Hemiplegia and disordered sensation are absent,
unless softening or pressure extend to the mesocephalon.

(4) Tumours of the middle lobes.

I have seen no case of tumour confined to the middle lobes.
Ladame enumerates twenty-seven cases, to which I have
added notes of four others. In several of Ladame's cases,
however, the mischief involved the rest of the hemisphere
also, or involved the mesocephalon. Ladame only mentions
hydrocephalus in two cases. External squint, as we should
expect, now becomes more common, and occurs in about one-
fourth of the cases. Ladame records amaurosis or amblyopia
in seven out of twenty-seven cases. Galezowski records very
carefully a case in which a fibro-plastic tumour of the right
middle lobe caused amblyopia, and after death was seen to
compress the mesocephalon forwards and downwards. The
thalamus, tract, and geniculate body were also crushed. Indeed,
even the bones at the base were injured, so that the case may
.be considered too extreme a one for our present purpose. The
size of the tumour is not mentioned. As hydrocephalus does
not seem to be a very frequent companion of tumours in this
seat, amaurosis, when it occurs, is probably due rather to the
direct action of the tumour in the way of pressure or soften-
ing. In Case 84 in the Appendix, however, an ounce of
fluid was found in the ventricle of the opposite side. In

v.] INTRACRANIAL DISORDERS. 149

most of Ladame's cases in which amaurosis is mentioned,
compression of the optic nerve is recorded among the post-
mortem discoveries. We have no means of knowing, as yet,
how often the mirror would reveal congestive changes in the
disk in tumours of the middle lobes, but probably much less
often than in tumours originating at the base. I publish one
of my own cases in the Appendix (No. 84) in which optic
neuritis was present.

The nearness of the mesocephalon explains the frequent
occurrence of palsy of motion and sensation in cases of tumour
of the middle lobes. Ladame found hemiplegia in half of his
cases, and slighter palsy in many more ; disturbed sensibility
he found in ten cases. I have a curious case now under my
care in which many good observers accept my diagnosis of
tumour of the right middle lobe with the thalamus, and in which
there is some weakness of the left side, but more especially
a curious degree of anaesthesia. When his eyes are closed,
the endeavours of this patient to pick up anything upon the
table are very odd failures ; indeed, he often has the object in
his hand without being aware of it, and continues his groping
efforts. There are no ophthalmoscopic signs. Headache in
the parietal region is generally present, but psychical de-
rangement is absent in one half the cases, or even more, at
any rate during the earlier stages. On the whole a some-
what greater frequency of amaurosis and the appearance of
deranged sensibility distinguishes tumours of the middle from
those of the anterior lobes. When the disease is on the left
side, there would probably be some frequency of aphasia.

(5) Tumours of the posterior lobes.

My own experience seems to be peculiar in the matter
of the connection of amaurosis with tumours of the posterior
lobes. Of Ladame's fourteen cases amaurosis occurred in two
only, and he grudges the symptom in one even of these, as
he will have it to have been an accidental complication.
I have had, however, one case of tumour of a posterior lobe
attended with amaurosis, the heads of which are given in the
Appendix (No. 86). I publish there also another (No. 57), quoted

150 OPHTHALMOSCOPE IN [CHAP.

from Dr. Lomax of Philadelphia, which ma'y be considered
here though the mischief was probably rather of a sclerotic
kind. Grafe (loc. cit.) gives a case in which optic neuritis co-
existed with headache and convulsion, and in which a myxoma
the size of a small apple was found ' at the posterior extremity
of the right hemisphere.' Lancereaux, again (loc. oil.}, quotes
a case (Bainbridge, ' Med. Times/ April 10, 1840) of a child
of nine, who had headache, vomiting, convulsions, and amau-
rosis as consequences of a 'medullary sarcoma' of the left
posterior lobe. The corpora quadrigemina were here found
softened and pulpy. In a case of hydatid of the left posterior
lobe with amaurosis recorded by Dr. Barker in the tenth
volume of the ( Pathological Transactions,' no mention is
made of the state or position of the mesocephalon. In
Dr. Hughlings Jackson's case (Appendix, No. 85) the choked
disk coexisted with dilated ventricles. Finally, Galezowski
(loc. cit.) records a case in which amaurosis slowly came
on with other and obscure cerebral symptoms ; mischief
was found in both posterior lobes, and the corpora quadri-
gemina were injured, partly indeed destroyed. Amaurosis
must, I think, occur more frequently therefore in conse-
quence of tumour of the posterior lobes than is generally
said to be the case. When it does occur I am disposed to
attribute it in many cases to interference with the corpora
quadrigemina, either by means of transmitted pressure or
transmitted softening. If this be so, the ophthalmoscopic
appearances should be distinctly subsequent to the first com-
plaint of dimness or of blindness, and the only change to
be looked for in the disks should be atrophic. In other cases
no doubt hydrocephalus is the nexus, as in No. 85. The
posterior lobes lie close upon the straight sinus and the veins
of Galen, so that ventricular dropsy would soon have reason
to appear. Such a case is also published by Bateman in ' The
Edinburgh Medical and Surgical Journal' (1805), vol. i.
p. 150. The case is re-published in the Appendix (No. 66).
That the swelling in this case was an abscess, need not,
I think, prevent my quoting it in the present connec-
tion. As regards the other symptoms of tumour of the

v.] INTRACRANIAL DISORDERS. 151

posterior lobes, we find that psychical disturbance is very
common, a clinical fact which bears closely upon some recent
speculations by Bastian and others concerning the function
of these lobes, and of the remarkable cells contained in their
convolutions. There can be no doubt that the mere anterior
position of the frontal lobes excites a prejudice in their favour
which is unreasonable. Vomiting, again, is commoner with
tumours of this seat than when placed more forward. Con-
vulsions also are prominent, as in all mischief irritating the
cortical substance. Headache, sometimes occipital, but more
often of a general character, is rarely absent. Disturbances
of sensation are as rare as in tumour of the middle lobe they
are common. Complete hemiplegia is rarely seen in simple
cases.

(6) Tumours of corpus callosum.

I only have before me the four cases collected by Ladame.
The symptoms of tumour of this region seem to be those
of tumour of the hemispheres. In no instance was sight
affected, nor was it affected in the cases of deficient corpus
callosum recorded by Langdon Downe.

(7) Tumours of corpora striata and thalami.

It is a curious commentary upon the thalamus opticus,
that tumours therein do not affect vision with anything
like constancy. If they involve the hinder and outer por-
tion of the thalamus, one would surely look to see the sight
affected and the nerves injured, but I think, as a matter of
experience, that tumours, like bleedings, rather prefer the
forward portion and the striate bodies. Nevertheless, among
the large number of cases of which notes are before me,
involving the under and hinder part of the thalamus, I
certainly find many in which tumours were discovered,
and yet no visual defect is mentioned. This curious result
reminds us of the fact that haemorrhage, which so often
affects these bodies, has rarely a destructive effect upon
vision. Galezowski found defect of vision recorded in seven-
teen cases out of sixty-two of lesions of the thalami. I have,

152 OPHTHALMOSCOPE IN [CHAP.

indeed, numerous cases before me in which amaurosis was
seen in tumour of this region; but many of these are the
sort of exception which prove a rule. In one case of amaur-
osis a tumour was found in the left thalamus, but there
was also another in the left lobe of the cerebellum. M.
Bouchut, among the cases which, with and without proof,
he records as tumours of the encephalon, gives one case
with an autopsy. In this case congestion of the disks was
noted during life, and three tumours were found in the left
striate body and thalamus after death. But there was also
a tumour in the medulla oblongata. In this case M. Bouchut
found the left disk more cedematous than the right, and
from this and other cases he hazards the assertion, that we
may in such cases determine the side of the lesion by the
side of the chief optic trouble 34 . I believe there is no
good ground for this supposition ; in my own experience,
accident enters far too much into the genesis of symp-
tomatic changes in the disks to enable us to draw definite
conclusions of this kind. But this by the way 35 . If I
analyse further the cases of tumour of the thalamus or
striate body which were attended with amaurosis, I come
to a case of Friedreich's (loc. cit.} in which amaurosis co-
existed with a tumour the size of a hen's egg in the right
thalamus. Here, however, this careful pathologist notes
that the corpora quadrigemina were quite crushed. Another
very interesting case is recorded, too, by Ley den in Virchow's
' Archiv.' for 1864 (B. xxiv.); but in this there was pressure
upon the vein or veins of Galen, and consequently hydro-
cephalus was a prominent feature at the autopsy. The
tumour was in the left thalamus, and was the size of an
apple. In a case recorded by Dr. Johnson in the * Med.
Chir. Rev.' Jan. 1836, there were cysts in the left ven-
tricle beside the mischief in the thalamus; and in a case
recorded in the ' Lancet' (1850, p. 682), a carcinoma in
the left thalamus not only caused amaurosis, but a degree

34 'Du Diagnostic des Maladies du Systeme Nerveux,' p. 318.

35 I may say here, that the many assertions we see in case reports, that one
eye alone was affected, have no value unless the mirror was used.

v.] INTRACRANIAL DISORDERS. 153

of dilatation of the pupils and of involuntary micturition
which suggest that the tumour involved also the neigh-
bourhood of the corpora quadrigemina. I myself recently
had an autopsy upon a case of tumour in the right thalamus
and corpus striatum, which I had attended in consultation
with Mr. F. Hall of Leeds. There were no ophthalmoscopic
signs of change during life, but a sarcoma the size of a hen's
egg, occupying the right striate body and the anterior half
of the thalamus, was disinterred, and it was surrounded by
a layer of atrophic softening. The optic* nerves and corpora
quadrigemina were normal, the sinuses were free. On the
other hand, I am now attending a man under the care of
Mr. Mann, of Leeds, in whom we have reason to suspect
tumour of the right corpus striatum, and he has well-marked
choked disks. In the thirteenth volume of the 'Medico-
Chirurgical Transactions/ a well-known case of tumour of both
thalami with amaurosis is reported by John Hunter, junior ;
but there was great disturbance of almost all the encephalic
functions. Absence of optic changes seems, then, to be com-
mon, perhaps the rule, in tumours of the striate bodies and
thalami which do not press upon the corpora quadrigemina or
the veins of Galen, and this seems to bear somewhat against
the vasomotor theory of optic disturbance. Fortunately, there
are other symptoms of a more constant kind, in the disturb-
ance of the motor tract. Convulsions are generally present,
and contralateral hemiplegia of more or less severity, ac-
cording to the degree in which the motor fibres are thrust
aside or sundered. Some degree of loss of memory and
mental application is generally present, and speech is gene-
rally affected in some measure, though rather in the way of
drawling or defective articulation than of aphasia proper.
Vomiting and constipation occur in many but not in most
cases, and severe headache is less frequent than in tumours
which grow nearer the membranes.

(8) Tumours of the crura cerebri.

Tumours of the crus are not very uncommon. I have
records of eleven cases before me, and they bear out the

154 OPHTHALMOSCOPE IN [CHAP.

belief that lesions of the cms are easy of diagnosis. The
best essay upon the pathology of these cases is by Dr. Her-
mann Weber, and is contained in the twenty-sixth volume
of the ' Medico-Chirurgical Transactions.' His cases, how-
ever, were not cases of tumour. In addition to the invari-
able or almost invariable lesion of the oculomotorius, visual
defect is often noted. A case is reported by Mr. Paget
in the 'Medical Times' of February, 1855, in which a
tumour of an inch in length and half an inch in thickness
was found in the right crus of a man aged 41. There was
anesthesia of the right arm, dizziness, palsy of left face,
and oculomotorius and convulsions of the limbs of the same
side. The sight was weakened 36 . In a case quoted from
Mohr by Ladame, in which amblyopia was found, a tumour
in the left crus was seen to compress the corpora quadri-
gemina, and to have involved them also in a belt of
softening.

Dr. Hughlings Jackson, again, records a case (Appendix,
No. 88) in which optic neuritis coexisted with a tumour
of one crus. In a case lately cited by Dr. Hoffmann,
and quoted in several journals, in which a tumour the size
of a cherry-stone was found in the left crus, the following
symptoms were noticed: paresis of the left limbs, some
anaesthesia of the left face, palsy of the left oculomotor
nerve, and amaurosis of the right eye, with atrophy of the
nerve. The left eye was affected with glaucoma. On the
whole, then, clinical experience bears out what anatomy
would suggest, namely, that swellings of the crura which
lie so near the optic tracts, corpora geniculata, and corpora
quadrigemina, tend often to involve and injure these parts,
and to set up a corresponding defect of vision. As regards
the ophthalmoscopic appearances in particular, we have only
Dr. Jackson's case to guide us; but I am disposed to guess
that primary atrophy due to compression or softening of

36 If I may depart from the subject in a note, I would refer also to the
incontinence of urine recorded in this interesting case, which reminds us
of Budge's assertion, that contractions of the bladder are caused by irritating
the crura cerebri.

v.] INTRACRANIAL DISORDERS. 155

the visual centres or tracts, would be a commoner result
than optic neuritis in cases, that is, of tumour of the crus
uncomplicated with meningitis. I have an interesting case
under my care at present, presenting complete palsy of the
left third nerve with decided and progressing palsy of the
right nerve also. For the rest, motion, sensation, and intellect
are unaffected. I believe the case to be one of tumour; it
is scarcely worth reporting without an autopsy, but I may
state that primary atrophy of both optic nerves is present.
It may be, however, that the supposed tumour is in the
corpora quadrigemina. Tumours of the crus alone are too
small to raise intracranial tension, they do not press directly
upon the basal sinuses, and they are perhaps more likely to
compress or soften the parts of vision than to irritate them,
unless meningitis be present 37 . The other symptoms of
tumour of the crus are palsy of the oculomotorius on the
same side (this is almost invariable, and the tumour soon
involves the origin of the opposite oculomotor), dizziness
(depending more or less upon diplopia), disorders of both
sensation and motion 38 , the latter (if not the former also)
being contralateral. Paralysis of the facial on the opposite
side is common, and may perhaps be due to disturbance
of certain fibres which are now said to pass from the motor
ganglia, through the crura, to the nuclei both of the facial
and hypoglossus. Weber considers that the vagus is espe-
cially involved in disease of the crura; but his opinion is
not supported in any definite way by my cases. Headache
is less common than dizziness, and vomiting and constipa-
tion, though present in some cases, do not seem generally
to be well marked. The mental functions are not implicated
until quite the later stages of the disease.

87 In one of Dr. Weber's cases (loc. cit.) one optic nerve was found to
be degenerated in the part which bordered upon the crus.

38 Weber says that sensation is disturbed on the opposite side. This seems,
however, as yet uncertain. I may say that I collected a number of cases for
publication about a } r ear ago, to prove that lesions of a certain district of the
foot of the crus outside the thalamus cause cutaneous anaesthesia. I still
intend to publish these cases, but I find that others have said my things before

156 OPHTHALMOSCOPE IN [CHAP.

(9) Tumours of the cerebellum.

The very common association of amaurosis with diseases
of the cerebellum is an old subject of speculation, and some
pathologists have been tempted to suppose that the cerebellum
is in some way a visual centre. Such is certainly not the case;
but, as we shall see, it is by no means easy to explain the
reason why disease of the cerebellum so often sets up disease
of the optic nerves. That absence of the cerebellum does
not include absence of vision, is clear from the well-known
cases published by Cruveilhier 39 and Combette 40 , in which
there was a congenital absence of the cerebellum with pre-
servation of the special senses, and of sight in particular.
In these cases the corpora quadrigemina were intact. Two
main points offer themselves to us when we seek an explana-
tion of the influence of cerebellar disease upon vision : the
first is that no function has as yet been definitely appro-
priated to the cerebellum ; and, secondly, that, isolated as
the organ seems to be, yet its troubles have nevertheless a
way of making themselves felt beyond itself. I have the
records of one hundred cases of tumour of the cerebellum
now before me, and I might easily have added to the number,
had I thought it worth while. Seventy-seven cases are
tabulated by Ladame. The very variety and multiformity
of the symptoms in these cases is sufficient to show that
no generalization can be drawn from them unless it be of
a negative kind, and to show, moreover, that diseases of
the cerebellum, when they reveal themselves, do so rather
indirectly by setting up secondary disturbances elsewhere.

It seems likely, indeed, that the only symptom which
really belongs to disease of the cerebellum itself, is a degree
of weakness of the limbs which does not amount to definite
palsy. To call the organ a centre of motor co-ordination,
is, to my mind, a very thoughtless hypothesis, for surely
every point in the body where two nerve-fibres are brought
into functional relation, is so far a centre of co-ordination.

39 ' Anat. Pathol.' vol. i. part 15, p. 5.

* 'Journal de Physiologic, par Magendie,' vol. xi. p. 27. 1831.

v.] INTRACRANIAL DISORDERS. 157

The cerebellum appears to me to be rather a reservoir of
force where, by the means of the posterior columns, tension
is stored up during" times of repose to be given out during
times of demand. Want of capacity of motion rather than
palsy, is what we should look for in the loss of such an
organ. I must not, however, pursue this point farther now,
but I have much evidence in support of my view, derived
both from human and comparative physiology. It is suffi-
cient for present purposes to dissociate vision from the
possible functions of the centre.

As to the second point, which is the remarkable disturbing
power which diseases of the cerebellum have upon the other
encephalic centres, I have more to say, as aifection of vision
is included among these interferences. It is unnecessary for
me to relate cases in which tumour of the cerebellum has
coexisted with amaurosis, for the coincidence is universally
admitted to be common. I publish one case, however, which
was kindly sent to me in manuscript by Dr. Roberts of Man-
chester, in further proof of the fact, sometimes disputed, that
amaurosis is often found in connection with diseases of the
cerebellum which are not tumours. Dr. Dickenson and others
have published similar cases of cerebellar softening with
amaurosis.

Among the symptoms of cerebellar disease which are not
due to the nerve destruction of its own tissue, but to inter-
ference with other parts, are occipital headache, due probably
to stretching of the tentorium and membranes ; troubles
in swallowing, circulation and breathing, due to interference
with the medulla; irritation of the genitals, due perhaps
to irritation of the same region; convergent squint and
dilatation of pupils, due to interference with the nucleus of
the sixth nerve and with the quadrigeminal bodies ; con-
vulsions, due to interference with the great underlying motor
strands below the fourth ventricle ; vomiting, of uncertain
causation, but occurring rather in cases of congestion and
swelling mischief than of mere nerve tissue destruction ; and
so on to amaurosis, occurring with both kinds of mischief,
and the cause of which we have to learn, if we can.

158 OPHTHALMOSCOPE IN [CHAP.

Let us now begin to learn from the other side, and ask in
what way the optic nerves betray their disturbance ? Unfor-
tunately, in very few cases have we the control of the mirror
to satisfy us in this matter. Galezowski (op. cit.) gives a
case of tumour of the cerebellum with the ophthalmoscopic
appearances. The state of the disks seems to have been
ischsemic rather than neuritic, though he calls it neuritis, and
refers it to propagated irritation by way of the processus ad
testes. A tumour was found in the < antero-inferior ' part of
the cerebellum upon the petrous bone, and thrusting the left
lobe towards the median line. The retina was oedematous and
infiltrated, and many little haemorrhages were found in it. The
optic nerves were softened and degenerated, and the chiasma
was ' small, greyish, and pulpy/ The state of the ventricles
is not mentioned. In a case of myxosarcoma of the cerebellum
described by Leber (in the ' Arch. f. Ophth.' vol. xiv. part ii.),
he observed a state of the disks suggestive of the passing away
of the choked disks and the commencement of subsequent
atrophy. After death the disks were thickened with increase
of connective tissue, while the length of the nerves presented
only atrophied fibres with fat granules. Atrophy of the disks
was complete before death. In the Appendix, again (No. 92),
will be found a case of tumour of the cerebellum also attended
with the choked disks. Although our knowledge of the ap-
pearances of the disks in the early stages of disease secondary
to cerebellar tumour is thus defective, yet we have ample evi-
dence that in the later stages white atrophy is very common.
At this period sight is more or less lost. Certainly it would
seem that primary atrophy atrophy without blurring or
ragged edges is a very common result, and that in cases of
cerebellar tumour, sight is soon affected, and dimness quickly
advances to blindness. Amaurosis pure and simple, white
atrophy with loss of sight, and probably not preceded by
neuritis or ischaemia, seems, if we may judge from clinical
histories, to follow tumour in this region more decidedly
than tumour elsewhere, save at the anterior base. What we
have to account for seems to be, first, primary atrophy;
secondly, and less commonly, the choked disk; thirdly, and

v.] INTRACRANIAL DISORDERS. 159

probably less commonly still, neuro-retinitis. Now how are
we to explain these occurrences ? Galezowski, following many
other writers, says unhesitatingly 41 , 'We can only attribute
the amaurosis in cerebellar affections to the propagation of
secondary inflammation up to the optic centres' (corpora
quadrigemina) . At present, we have only to deal with cases
of tumour, and in these cases I very much doubt the accuracy
of this somewhat positive conjecture.

I have said that in examining the injured tissues which
surround encephalic tumours I fail in the large majority of
cases to find any evidence of acute proliferating processes,
and that I find evidences rather of occlusion of blood-vessels
with simple degradation and traces of haemorrhage. That
softening may extend to the corpora quadrigemiDa by way
of the processus ad testes I think likely, but I wait to be
convinced that any inflammation reaches them. Progres-
sive softening, reaching the visual centres, is probably one
cause of loss of vision and of nerve atrophy. When we
further consider the position of the cerebellum, and re-
member how closely it is invested by its containing struc-
tures, by the rigid occipital box, and by the dense tentorium,
we shall see at once that any enlargement of its volume,
however slight, must soon exercise strong pressure upon the
walls of its box. Pressure upon the occipital bone means
pressure upon the lateral sinuses, and pressure upon the ten-
torium also means pressure upon the straight sinus, upon the
outlet of the veins of Galen, and upon the torcular Herophili
itself. It is evident, then, that slight enlargements of the
cerebellum must very soon interfere seriously with the reflux
of nervous blood. Again, if we leave the blood-vessels and
turn to the relative position of the soft parts, it is clear that
in enlargement of the cerebellum, especially of its median
and anterior parts, there must be a resolution of the pressure
in the direction of the mesocephalon, as this is the direction of
least resistance. Were this found to be the case, we should see
the corpora quadrigemina flattened, and we should infer that
their function was suppressed. In the notes before me, I do
41 Loc. cit. p. 1 66.

160 OPHTHALMOSCOPE IN [CHAP.

not find that special attention has been given to this point,
though the very frequent mention of ' pupils widely dilated '
is suggestive of pressure upon the corpora quadrigemina.
As regards the transmission of softening to the corpora
quadrigemina, I find in one case (No. 85 of Ladame) that
softening of the corpora quadrigemina and atrophy of the
optic nerves was found to coexist with a cerebellar tumour
of the size of a hen's egg. Amaurosis was among the
symptoms. It would seem to me, then, that softening and
pressure, rather than inflammation, are the agents of in-
terference with vision. But it is to the interference with the
venous circulation that I would attribute the amaurosis in a
large number, if not in the majority, of cases of cerebellar
tumour. We have seen how this interference takes place, and
we shall no longer be surprised to find that ventricular dropsy
is consequently found in so great a proportion of these cases.
Hydrocephalus is actually mentioned in the majority of cases,
and, so carelessly are autopsies made or noted, in many more
where no allusion is made to the state of the ventricles, we
may suppose that it existed to some degree at least. Now
I have already pointed out how large a part is played by
ventricular dropsy in causing optic atrophy, and if I turn
to my cases of cerebellar tumour I do not lack further
evidence on this part. Not only must the great dropsy
of the side ventricles have compressed the optic tracts in cases
where, however, no examination of the tracts is recorded,
but I find in several cases, that the direct pressure of a
distended third ventricle upon the chiasma was observed
and noted. In case No. 67 of Ladame, for instance, we
read, Moss of vision and third ventricle distended.' In a
case published by Bouchut, in the ' Gazette des Hopitaux/
No. 144(1854), we read, 'complete amaurosis,' 'third ven-
tricle distended ; ' and in a case which came under my own
observation, a distended third ventricle had flattened and al-
most destroyed the chiasma, which was thin, grey, and scarcely
consistent. If neuro-retinitis were found in a case which
presented the symptoms of cerebellar tumour, I should attri-
bute it to meningitis. I can find no evidence to lead me

v.] INTRACRANIAL DISORDERS. 161

to suppose that tumours, although they may be called
'foreign bodies/ set up irritative proliferation which travels
along brain substance from the cerebellum to the eye; and,
on the other hand, I find that meningitis has been found
to coexist with cerebellar tumour in many autopsies, especially
when these tumours were superficial. Cerebellar tumours,
moreover, are often tubercles, and in these cases a coexistent
tubercular meningitis of the base would be likely enough.
To sum up, then, the frequent concurrence of amaurosis
with cerebellar tumour depends chiefly upon the neigh-
bourhood of the corpora quadrigemina, and of the great
encephalic veins and sinuses. Its causation is most com-
monly due, perhaps, to the ventricular and subarachnoid
dropsy, which results from venous stoppage, and which
crushes the nervous centres or tracts of vision, or in an early
stage chokes the optic disk. In other cases it is due to the
advance of softening from the circumference of the tumour
along the processus ad testes to the corpora quadrigemina.
The optic nerves waste, either as a consequence of the destruc-
tion of the visual centres, or because they are themselves
compressed. In many cases, where the mischief is due to
venous arrest, a period of strangulation may be seen to
precede the more complete destruction, if sought for in time.
The state of ischaemia papillae, indeed, has no doubt existed
in some cases where no disturbance of vision is recorded, and
where few or no ophthalmoscopic examinations were made.
True neuro-retinitis seems to occur but rarely, nor should we
expect it to occur, save when meningitis is present. In
cases of tuberculous tumours, meningitis of the base may be
often present, and neuro-retinitis may be its consequence. In
very superficial tumours of the cerebellum, as of other super-
ficial parts of the encephalon, adhesive meningitis is also a
common event, and may, in rare cases, propagate itself to
the middle fossa, and so to the optic nerves.

I have already (page 157) enumerated the various other
symptoms which must be looked for in connection with the
optic signs in cases of tumour of the cerebellum.

162 OPHTHALMOSCOPE IN [CHAP.

(10) Tumours of the crura cerebelli.

Ladame gives two cases only of tumour of the pontine
crura of the cerebellum, but to these I have been able to
add seven more. I make a separate heading of these cases,
because in six cases vision was profoundly affected, in two
vision is not mentioned, and in one vision was unaffected, but
neuritis was discovered by the mirror. In this last case
only have I notes of the ophthalmoscopic appearances : the
case is published by Mauthner, in his ' Lehrbuch der
Ophthalmoscopie,' p. 293. In the right crus cerebelli ad
pontem was found a sarcoma the size of a walnut. There was
considerable dropsy of the ventricles. (Vide Appendix, No.
91.) The ophthalmoscopic appearances bear out the conjectures
I have previously made concerning the mediation of hydro-
cephalus in these and like cases, and concerning the effects
upon the eye. Although Mauthner uses the expression f fully-
developed neuritis' in describing the state of the disks, yet
this was not descending neuritis, for at the autopsy the
microscopical examination showed that the mischief was quite
confined to the disks, the nerve above and the retina beside
being quite normal. It adds to the significance of this
striking case, that it is the only case in which vision
is reported to be unaffected. Mauthner says distinctly,
that the patient enjoyed perfect sight up to the end of
his life (' voile Sehscharfe bis an sein Lebensende ') . Here,
then, clearly we had not to do with pressure on the corpora
quadrigemina, or with destruction of these bodies, as was
probably the case in some of the other like instances in
which amaurosis was present ; but we may assume that the
ischsemia of the disks was due to the pressure of the
hydrocephalus upon the cavernous sinus, or that the ischsemia
and hydrocephalus were common direct results of the venous
arrest caused by the tumour.

I have notes of three cases of tumour of the superior
peduncles alone, and in all three sight was affected; these
cases corroborate my remarks in the previous section, to
which I need not make any addition. Among the con-

v.] INTRACRANIAL DISORDERS. 163

comitant symptoms of lesion of the crura cerebelli come
those remarkable lateral movements, or movements of rota-
tion of the head and body, which have been noticed in these,
and in some other one-sided lesions, by many observers.
Headaches and dizziness also occur, and hemiplegia, which
probably depends upon more or less interference with the
great motor strands continuous with the crura cerebri.

(n) Tumours of the corpora quadrigemina.

Hitherto, in classifying our tumours, we have not been
very careful to be sure that they were limited to the
part under discussion. In cases of tumour of a lobe of
one hemisphere, for instance, we were already pretty sure that
it could only affect vision by affecting also some part of
the encephalon other than its nominal seat, and we had
to learn whether this was commonly the case. Latterly,
however, we have had to look more carefully to the exact
seat of the tumour, and in discussing the effect of tumours
of the corpora quadrigemina upon vision, we have to look
minutely to the very place of the tumour, as we are led
to suppose in this case that the tumour destroys vision
directly by abolition of these ganglia themselves, and not
by abolition of some neighbouring or connected part. We
have certainly found amaurosis commoner as the tumours
approached these bodies, and we have now to investigate
the effect of tumours actually in them.

Obscure as the matter yet remains, we do nevertheless
attribute visual perception to the corpora quadrigemina, if
we make any assertion on the subject at all. Comparative
anatomy and experimental physiology seem to point to the
quadrigeminal bodies as optic ganglia, if not the only ones.
The functions of the geniculate bodies, closely intimate as
they are with the optic nerves, seem as yet unknown 42 , nor
have we determined the functional relations of the little
nucleus in the thalamus which has been so well demonstrated

42 It seems probable that they are a medium of communication between the
nerves of vision and the hemisphere or brain proper, while the nucleus in the
thalamus may coordinate visual with general sensation.

M 2

164 OPHTHALMOSCOPE IN [CHAP.

by Dr. Broadbent. These associated ganglia must be concerned
with vision, and the comparatively small number of fibres
which do reach the quadrigeminal bodies may possibly be only
the fibres which co-ordinate the movements of the iris with
the impressions upon the optic nerve. After all, however,
there does seem to be a certain constancy in the result of
early and complete blindness in cases of destruction of the
quadrigeminal bodies which we have not found, or have not
proved, in the lesions of any other centre. In destruction of
the quadrigeminal bodies with amaurosis, we find, moreover,
that the early and remarkable dilatation of the pupil also
occurs, which is admitted to be due to an interference
with their functions in such states as hydrocephalus, and
which suggests to us that not only this but the blindness
also is due to such interference. I lay the more stress
upon this point, as in the two cases of quadrigeminal
tumours recorded by Ladame, and in which amaurosis is
not mentioned, dilatation of the pupil was also absent.
In four other cases collected by myself 43 , on the other
hand, and in which amaurosis was present, dilatation of
the pupils is distinctly mentioned as an early and re-
markable occurrence. This fact makes me unwilling to
accept Ladame's cases as evidence against the connection of
amaurosis with lesion of the quadrigemina. The cases may
be exceptional, and the mischief did not perhaps de-
stroy the ganglia, though in one case it is certainly
reported that the bodies were wholly transformed into tu-
bercles. Whether, in case of destruction of the quadri-
gemina, other ganglia may still keep up vision, must no
doubt remain an open question, but it must be remembered
that both Ladame's cases occurred in small children (one
a year and three months old, and the other three years
old), and that no ophthalmoscopic examination was made
in either. Jobert de Lamballe seems to have given special

13 There is a case of tumour of the corpora quadrigemina with early and
complete blindness recorded by Dr. Cayley in the sixteenth volume of the
' Pathological Transactions.' I have not included it, however, as it was com-
plicated with hydrocephalus.

v.] INTRACRANIAL DISORDERS. 165

attention to amaurosis consecutive to alterations of the
corpora quadrigemina, in his ' Etudes du Systeme Nerveux.'
I have not had the opportunity of consulting this work,
but his observations are quoted by several writers. He
recounts several very interesting cases of blindness caused
by destruction of these bodies, and in one curious case he
discovered a tumour compressing the left corpora more than
the right. In this way he explains what was observed during
life, namely, that the right eye became blind before the left ;
which is also in accordance with the conclusions of Flourens.
The pupils are said in his cases to have been widely dilated
at an early stage of the amaurosis. In two of my four
cases I must admit that other parts were affected as well
as the quadrigemina. In the first, recorded by Wagner 44 ,
a new formation of the nature of connective tissue existed
in these bodies, but had also involved the pons and posterior
fossa. Moreover, the mischief in the eyes was not mere
amaurosis, but neuritis 45 . In another case, given by Fried-
reich, a sarcoma the size of a hen's egg compressed the
quadrigeminal bodies, but it originated in the right thalamus.
The third case is reported by Rosenthal in his new volume 46 ,
and I have published an epitome of it in the Appendix (No.
90). In it, again, we are not free from the complication
of hydrocephalus, the backward pressure of which upon the
corpora quadrigemina always tends to dilate the pupils. The
fourth case is one of those of Jobert de Lamballe, to which I
have already alluded. Galezowski gives two cases of tumour
in which secondary softening of the quadrigemina was found ;
the tumour in one case was cerebellar, and the reporter was
M. Serres ; in the other case the tumour was in the posterior
cerebral lobe, and was under the observation of M. Renaud

44 ' Zehend. Klin. Monatsbl.' iii. p. 159, (1865). The case is given in the
Appendix (No. 89).

45 As the amaurosis seems to have been early and complete, there may have
been both actions at work. The centres may have been destroyed, and neuritis
may also have been propagated along the membranes at the base. I have a
strong conviction, however, from the description, that the disks only were in-
flamed or choked. The sinuses were greatly congested.

46 'Handbuch d. Nervenkrankbeiten,' p. 62.

166 OPHTHALMOSCOPE IN [CHAP.

and himself. These facts are very interesting and im-
portant.

On the whole, then, without asserting that obliteration of
the quadrigeminal bodies must cause blindness, yet I think
that the facts I have adduced, supported as they are by physi-
ological observation and experiment, justify me to some extent
in finding in their injury the cause of the amaurosis which
also accompanies destruction of parts which lie near them.
"We should be disposed to explain a case of amaurosis in
this way if we found that the blindness was early and soon
completed; that the reflex movements of the iris were ar-
rested, the iris being dilated in the periods of destruction,
and contracted in stages of irritation ; and, thirdly, that loss
of vision preceded a progressive atrophy of the optic nerves.
Among other symptoms, we should expect palsy of the orbital
muscles supplied by the third nerve, and convulsive or para-
lytic conditions of the limbs, according as the underlying
motor strands are more or less involved 47 .

(12) Tumours of the pom varolii.

Nothing would be gained by too curious a division of the
present subject, so that I omit any separate discussion of
tumours of the fourth ventricle and of the pineal gland, which
could only be of importance to us in the degree in which such
tumours affected regions other than their nominal seat. That
tumours of these parts must soon involve the quadrigeminal
bodies is obvious, and this is well illustrated by a case recorded
in the admirable work of Rilliet and Barthez. An eneephaloid
tumour was found in the cavity of the fourth ventricle, and
during life there was amblyopia, with early and remarkable
dilatation of the pupils 48 . It is strange that in a case recorded

47 Throughout this volume I have avoided any reasoning from cases not
examined after death, but I may be permitted to say that I have a case now
under my care which satisfies all these conditions, and another which may
be tumour of the corpora quadrigemina, to which I have referred in the
section on Tumours of the crura cerebri (page 155).

' 8 Vide a curious case of dropsy of the fourth ventricle with amaurosis,
recorded in the seventh volume of the 'Pathological Transactions.'

v.] INTRACRANIAL DISORDERS. 167

by Virchow 49 , in which the pineal gland was transformed into
a bladder the size of a small nut, which pressed upon the cor-
pora quadrigemina, there is no allusion to loss of vision or
dilatation of the pupils. There was also a tumour in the left
thalamus.

Of clinical with autoptical records of tumours of the pons
there is no lack. Ladame gives twenty-six cases, and to
these I have quickly been able to add twenty more, four
of which were under my own observation almost through-
out. Among these forty cases, there are twenty-five in
which dimness or loss of vision is recorded ; if to these
we add on speculation that unknown number in which
ophthalmoscopic changes were present but unseen, we shall
conclude that defects of the optic nerves are common in
tumours of the pons. This we should expect from their near-
ness both to the centres of vision and to the base of the cra-
nium. Quotations were made in the journals about four years
ago from an essay by Da Venezia, entitled ' Sintomatologia
dei tumori della protuberanza annulare ' (Gaz. Med. Lomb.,
No. 15). I have been unable to procure the periodical in
question, but I learn that he founds an analysis of symptoms
of tumours of the pons upon twenty-six cases, and among
disturbances of the parts of vision he notes : ' Convergent
strabismus, six cases ; divergent strabismus, one case ; dilata-
tion of the pupils, four cases ; inequality of pupils, two cases ;
amblyopia and amaurosis, ten cases 50 .' Hydrocephalus in all
probability is but a rare cause of amaurosis in tumour of the
pons, as I find it recorded in a small proportion only of the
cases before me. The nearness of the Sylvian aqueduct would
have led us to expect the result of hydrocephalus to be more
frequent, and the omission of it in some records may be due
to carelessness. It was not present in any degree in my four

49 'Krank. Geschwiilste/ ii. 658, note.

50 Man^ tumours which are really of the pons are nevertheless, so far
as position goes, tumours of the posterior fossa also. See, for instance, an
interesting case in the ' Pathological Transactions' (vol. v. p. 26), recorded by
Dr. Ogle, in which there was defect of vision. I have called those tumours of
the base, however, which originated there, and they are more likely to be
attended with meningitis.

168 OPHTHALMOSCOPE IN [CHAP.

cases ; but, on the other hand, it was present in a case attended
with amaurosis which is recorded by Virchow (loc. cit. vol. ii.
p. 666, note). The effusion was considerable, flattening the
brain ; the pons was broader and higher than normal, and
contained a tubercular tumour larger than a walnut. There
is a similar case recorded by Rosenthal (loc. cit. p. 77). I
have not been able to satisfy myself concerning any conclu-
sions to be drawn from the site of the tumour in the pons,
but I presume that the deeper the tumour the more should we
have amaurosis resulting from softening or crushing of the
quadrigemina and from hydrocephalus ; and that the more
superficial the tumour the less likelihood of amaurosis, save in
cases of concurrent meningitis. In two of my cases (vide
'Path. Trans.' vol. xix. 1868) the tumours were basilar, there
was no important meningitis, and the disks were unchanged
so long as the corneas remained transparent. In the other two
there was tolerably early interference with the disks, and sub-
sequently complete amaurosis, with dilatation of the pupils ;
the tumours were deep and surrounded by softening which
involved the vermiform process on the one hand, and the
region of the fourth ventricle, corpora quadrigemina, and (in
one case the) crura cerebri on the other. Both these cases
occurred in male adults, and the tumours were manifested
by many interesting collateral symptoms, upon which I intend
to comment at some other time. Meningitis was probably
the cause of amaurosis in two cases published by Mr. Salter
and Dr. Tyson. Mr. Salter's case is quoted by Ladame from
the 'Edinburgh Journal/ vol. xi. p. 270. There were two
superficial swellings upon the pons, and there was very con-
siderable exudation upon the arachnoid. There was at first
amblyopia in both eyes, and subsequently amaurosis of the
right eye. Dr. Tyson's case is recorded in the sixth volume
of the ' Philosophical Transactions/ There was a superficial
swelling the size of a cherry-stone upon the pons, and chronic
meningitis therewith. Amaurosis was among the symptoms.
I think we may suspect, therefore, that in cases of tumour of
the pons there is no tendency to amaurosis when the tumour
is superficial, unless there be meningitis as a middle term,

v.] INTRACRANIAL DISORDERS. 169

when we should find in the early stages either neuro-retinitis
or ischsemia papillae : that in deeper tumours, however, the
surrounding parts are constantly found to be softened or dis-
torted, such parts being the anterior half of the cerebellum, its
crura, the parts near the fourth ventricle including the cor-
pora quadri gemma, and even the crura cerehri. Hydrocepha-
lus, though not a common concurrence, is, however, when it
occurs, an efficient cause of amaurosis. In a word, the deeper
tumours of the pons, as regards their effects upon vision,
resemble tumours of the cerebellum, and of the vermiform
process in particular, except in their liability to cause hydro-
cephalus. Their presence would be betrayed, therefore, rather
by progressive atrophy than by choking of the disks. Neuro-
retinitis in deep tumours must be rare. The symptoms which
would coexist with the ophthalmic signs of tumour of the
pons are direct palsy of the face, and cross palsy and anaes-
thesia (less constant) of the limbs ; or bilateral palsies when
the tumour is bilateral, which is less common ; headache,
frontal or occipital; mental derangements, which are curiously
common, and often with depression (Da Venezia found them
in thirteen out of twenty-six cases) 51 ; inflammation of the
eyeball; difficulty of swallowing and articulation, and in many
cases loss of hearing. Vomiting, apart from dysphagic eruc-
tations, is less common, and convulsions are generally absent
unless there be some source of irritation, such as meningitis.
Da Venezia notes convulsions in but three cases out of twenty-
six, and in these three the lesions were not simple ones. The
state of the pupils, of which much has been said in lesions of
the pons, is inconstant, at any rate in cases of tumour. They
seem (amaurotic conditions apart) frequently to have been
normal, and, if contracted in a few cases, they have been
dilated in as many or more.

(13) Tumours of the medulla oblongata.
The effects of tumour in this region are not ascertained, as

51 It is perhaps not wholly foreign to my purpose to remind the reader that
the pons, according to recent researches, seems to be the centre of reaction
between emotions from the hemispheres and sensations from the exterior.

170 OPHTHA LMOSCOPE IN [CHAP.

the cases seem to be rare. Ladame has only collected nine
cases, and I know of no more cases with autopsies which
will help us. It is unlikely that tumours of the bulb are
attended with amaurosis unless they are complicated with
sclerosis or meningitis, or are large enough to involve the
encephalic centres above. The occurrence of amaurosis in
five out of Ladame's nine cases, seems at first to point to
a contrary conclusion ; but when we look into these cases,
we find that in the first of them there was a large tumour
filling the left posterior fossa, and hydrocephalus ; in the
second a tumour, as large as a chestnut, was placed under
the tentorium, and compressed also the pons and the cere-
bellum ; the third and fourth were like unto it ; and in the
fifth there was also a tumour of the cerebellum, and hydro-
cephalus 52 . In none of these cases can we pretend that
the amaurosis was a result of the tumour in the bulb itself.
I think, then, we should only look for ophthalmoscopic signs
in cases of tumour of the medulla oblongata when there is
coexistent meningitis. I have not met with an autopsy in
such a case, however, and merely give this conclusion for
what it is worth. As to other symptoms, paralysis of course
occurs, but less uniformly than we should suppose; convul-
sions, on the other hand, seem common ; disordered sensations
seem to occur irregularly, but are seldom absent. Other
changes far more dangerous to life also follow injuries of the
medulla, such as neuro-paralytic hyperaemia of the lungs.
Hiccough, vomiting, and disordered bowels are likely to occur
in such cases, though we do not find many facts at our service
to illustrate these points.

May it not be that the medulla is of too vital an importance
to the organism to bear much morbid change, and that persons
affected with the incipient forms of such change die before the
mischief grows to the size of a tumour? The pons varolii,
which presides over functions of less immediate value to life,
holds out longer, and as its changes are gradually propagated

52 In this case the ophthalmoscope was used, and progressive atrophy ascer-
tained. The corpora quadrigemina were crushed by the dropsy, and the optic
nerves were very cedematous.

v.] INTRACRANIAL DISORDERS. 171

downwards we perceive many symptoms symptoms among
those which I have recorded as belonging 1 to disease of the
pons, but which really are evidence of disturbance of the
medulla.

(14) Tumours of the anterior fossa.

As intracranial tumours approach the base of the skull, we
find amaurosis a far more constant symptom, a symptom,
indeed, upon which, in the case of tumours of the anterior
and middle fossae, we may almost count. It was by tu-
mours of the base that we were first taught the importance
of medical ophthalmoscopy, and these are the cases which
formed the basis of the earliest observations. A tumour of
the middle fossa can hardly avoid the optic nerves, and
tumours of the anterior fossa must involve them in a large
proportion of cases. Tumours of the base set up optic changes
in three ways. First, and most commonly, by direct injury
to the nerve, severing it from its connections and entailing
its atrophy ; secondly, by retarding the reflux of blood and
choking the disks ; thirdly, by irritation of the connective
elements of the nerves, with consequent neuro-retinitis. As
regards the latter event, I repeat once more that meningitis
in all probability is the middle term to which, rather than
to the morbid growth, the neuro-retinitis is directly due.
Many writers seem to think that it is only necessaiy to
call a tumour a 'foreign body' in order to explain neuro-
retinitis at once, having the notion, apparently, that ' foreign
bodies' are fidgetty masses which annoy all the structures
with which they come in contact. My experience is, that
many foreign bodies get on very comfortably with neighbour-
ing structures, and not infrequently establish tranquil rela-
tions of adhesion with them ; in such cases the optic nerves
are often squeezed quietly to death. In other cases the mem-
branes are inflamed in a way which does not seem to me very
easy to explain. In rare cases it may be that a tumour excites,
by continuity in the connective tissue, its own process of
active nuclear proliferation ; but I fancy that the commoner
process is the establishment of minute and miliary rents in

172 OPHTHALMOSCOPE IN [CHAP.

the tissue, these rents becoming, each one of them, a centre of
inadequate repair.

The anterior fossa or fossae of the cranium are limited
backwards by the smaller wings of the sphenoid, and they
lodge the anterior lobes of the brain. Disease of the nose or
orbits tends to invade this region, and to set up meningitis or
thrombosis of the encephalic sinuses with the optic signs I
have described, or to give rise to collections under or about
the membranes which are practically tumours. Aneurisms
of the anterior cerebral arteries generally belong to this
region (vide Case No. 80, Appendix), and may cause amaurosis.
If so, the amaurosis is of one eye only, one nerve being
crushed before the chiasma ; in many cases, however, en-
cephalic aneurisms give rise to few or no symptoms until
shortly before death. Exostoses and spiculae not uncommonly
take their origin from this part of the cranium, and may
or may not wound or crush one or both optic nerves. Caries,
again, with the meningitis, abscesses, thrombosis, and kindred
accumulations to which it gives rise, exercises ill effects
upon the optic nerve, and caries soon reaches the an-
terior fossae, if any such mischief be at work below the
orbital plates. Tumours of the anterior fossae, again, are
often related in origin to the periosteal dura mater, and by
destroying the nutrition of the orbital plates, or crushing
them, they encroach upon the orbits themselves. In these
cases there is more or less thrusting of the globes outward,
which facilitates the diagnosis. A very small depression
of the orbital plate will cause a manifest protrusion of the
eye, as this deformity, even when slight in degree, soon strikes
the observer. In an autopsy upon a case of my own, in which
there was, what seemed to us to be, considerable exophthal-
mos, we found the orbital plate but slightly depressed ; the
depression, however, had taken place over about two-thirds of
the area of the plate, making up in extent for its shallowness.
This patient had no difficulty in closing the affected eye. The
tumour was fibrous, and involved both optic nerves ; the
amaurosis was complete.

The perforating tumours, such as encephaloid or ' fungoid '

v.] INTRACRANIAL DISORDERS. 173

tumours, frequently make their way into the orbit and push
out upon the face, as, on the other hand, they may penetrate
from the eye into the head. There are many such instances
on record, and they scarcely call for further discussion
from the present point of view 53 . The olfactory lobes, the
ethmoid bone, and the nose are often sufferers in cases of
tumour of the anterior base ; and epistaxis is recorded in
some as an early symptom. In a well-known case of Cru-
veilhier, quoted by Mackenzie 54 and many other writers,
a tumour of the dura mater, seated on the ethmoid bone,
and spreading out into both anterior fossae, destroyed both
olfactory lobes and both optic nerves. The patient, whose
age and sex are not mentioned, having been long deprived
of the sense of smell, and latterly of that of sight, died
comatose. It is unnecessary to multiply cases of this kind,
which bring their own explanation with them, and offer little
difficulty of diagnosis.

(15) Tumours of the middle fossa.

It is hard to see how the optic nerves can escape in tumour
of the middle fossse, and as a matter of fact they seldom
do. Between the lesser wings of the sphenoid and the
superior border of the petrous bone we find the chiasma,
the sella turcica, the optic tracts, the third, fourth, and
sixth nerves, the ophthalmic division of the fifth, and the
cavernous sinus; we have here, moreover, a region very
liable to fracture, to caries, to aneurisms, and to tumours.
For the effects of fracture, however, I refer the reader to
page in. The pituitary body which lies here has itself a
proclivity to disease which, seeing that it lies directly above
the chiasma, is very inconvenient for that part. Tumours
of the middle fossse give rise, therefore, to very various
symptoms, and affect the disks in sundry ways. If me-
ningitis be present, we shall find ischaemia of the disks or
neuro-retinitis ; if the tumour directly compress the nerves,

53 Conf. e.g. Griife in many places, and especially 'Archiv. f. Ophthal.'
vol. i. part I, p. 417.

64 Third edition (1840), p. 869.

174 OPHTHALMOSCOPE IN [CHAP.

we shall find progressive atrophy. These tumours are easy
of diagnosis, but an ophthalmoscopic examination may some-
times be the only means of coming to a decision at an early
stage. Among tumours of the middle base, the enlargements
of the pituitary gland take an important place, for they are
not infrequent, and may attain considerable size. As I have
said, disease of this kind must crush the chiasma, it will
also involve the numerous nerves entering the orbital fissure,
and will probably press upon the cavernous sinus. Caries of
the sella turcica is not an uncommon event, and brings with
it symptoms very like those of tumour. Meningitis of the
base interfering with the venous ebb at the cavernous sinus,
and perhaps coagulating its contents, thus sets up ischsemia of
the disks ; or, propagating itself to the sheath and connective
trabeculse of the optic nerves, sets up neuro-retinitis. A case
of this kind was under my care four years ago ; neuro-retinitis
was present during life, and after death I found caries of
the saddle, together with meningitis and proliferation within
the optic nerve trunk, resembling that shown in the plate. In
tumour of the middle base, though both neuro-retinitis and
ischsemia may be present, yet primary atrophy is far more
common, and is the result of destruction of the trunks or
the chiasma by the growth. The pupils will probably be
dilated when the atrophy is complete, but will not appear
so soon as when the visual centres are compressed by central
tumours. I almost think that the absence of all symptomatic
change in the fundus would decide me in any given case against
the supposition of tumour in the middle fossa, and this I
believe is the only locality in which such absence would have
a decisive value. For example, an interesting case of this
kind came before me two years ago. Mrs. G. was sent to
Leeds by Dr. Beaumont of Harrogate, to be under my
care. She presented many symptoms of tumour of the
base. She suffered from intense paroxysmal headache, vomit-
ing, and diplopia; there was also slight ptosis, and external
strabismus of the left eye. These symptoms had lasted
about six months. As the disks were absolutely healthy,
I told Dr. Beaumont that I felt almost certain there was

v.] INTRACRANIAL DISORDERS. 175

no tumour of the middle fossa, and that I thought the
absence of neuro-retinitis during so long a time should
decide us also against syphilitic meningitis. Nor could we
discover any other evidence of syphilis ; but still it seemed
desirable to give trial to a full and prolonged course of
iodide of potassium. This was done with no benefit whatever.
As the paralytic symptoms were but slightly pronounced, and
varied somewhat with the headache, I ventured to side with
the ophthalmoscope, and to pronounce against the supposed
presence of any organic disease. Under the care of Dr. Beau-
mont, and the bold but watchful use of tonic remedies, this
lady quite recovered, and has now been in good health for
some time. These neuralgic conditions, which may exhibit
paresis of both motor and sensitive branches, are not very un-
common; they often mimick meningitis or basilar tumour,
but I think they may be distinguished from these latter states
by means of the mirror. The cases of tumour or enlargement
of the pituitary body recorded by Ladame are fourteen in
number, and many more may be quickly added. Strangely
enough, Ladame has not included the five cases upon which
the well-known essay of M. Rayer was based 65 , nor the
similar cases recorded by Morgagni and Bichat. Galezowski
refers to other cases again by Chevalier 56 and by Temputi, an
Italian physician 67 . In all these cases sight was affected or
abolished, and the optic nerves were found to be crushed. The
assertion of Wenzel, that disease of the pituitary body com-
monly accompanies epilepsy, is not supported by ophthalmo-
scopic evidence, though it is fair to remember that Wenzel's
cases were not cases of tumour. Tumours of the chiasma itself
are not very rare ; these are sometimes cystic, as in a case
quoted by Galezowski, sometimes solid growths, as in the fol-
lowing case put on record by Hjort. A man aged 44 suffered
from headache and palsy of the right facial and oculomotorius
nerves. The left half of the field of vision was lost on both
sides, which corresponded with the discovery after death of a

55 'Archives Generates de Medecine' (1823), t. iii. p. 350.

56 'Journal Universel' (1828), t. xlix. p. 113.

57 'Gaz. Med. Italiana toscana,' 1851. Quoted by Galezowski, loc. cit.

176 OPHTHALMOSCOPE IN [CHAP.

tumour the size of a hazel-nut seated upon the right half
of the chiasma 58 . The curious precision of the injury in this
case might have led to a diagnosis of the origin of the lesion,
but of course such tumours cannot as a rule be distinguished
by their symptoms from tumours of the pituitary body, nor
these again from other small tumours of the middle base. In
all such cases we shall find paroxysmal headache in the frontal
and temporal regions; ciliary neuralgia; early and effectual
injury to the optic nerves, generally of a primarily atrophic
character; and palsy of the nerves which traverse the base
of the skull, with secondary mischief perhaps of the conjunc-
tiva or eyeball. We shall not find the loss of smell and
speech which belong to tumours of the anterior fossae, on the
one hand, nor the loss of hearing and frequent motor palsy
which belong to tumours of the posterior fossa on the other.
In a very interesting case published by E/osenthal (loc. cit.
p. 66), melituria accompanied headache and primary atrophy
(the eyes were examined by Jager), the cause being a sarcoma
the size of a walnut upon the hypophysis. No mischief was
found about the fourth ventricle, but no microscopical exami-
nation seems to have been made.

(16) Tumours of the posterior fossa.

I have nothing of importance to add here to what has
been said in the sections treating of tumours of the pons
varolii and of the cerebellum. If the tumour be placed upon
the occipital bone, amaurosis is less likely to occur than when
it is placed upon the basilar process, or petrous bones. The
reasons for this are already explained, being the same as
those which explain the occurrence of amaurosis in cases of
mischief in the antero-inferior district of the cerebellum.
Hydrocephalus, which is not common in tumours of the
anterior and middle fossse, is far more common in tumours
of the posterior fossa. It is impossible to say in any given
case whether the tumour be placed in the dura mater or

58 ' Jahresbericht,' Virchow (1867), ii. p. 497.

v.] INTRACRANIAL DISORDERS. 177

in the neighbouring- part of the encephalon, nor indeed is
it important. A very early and complete interference with
either branch of the seventh nerve would be suggestive of
the former position, while early paralysis of the limbs would
suggest the latter. Neuro-retinitis, being indicative of
meningitis, if it occurred early would suggest a tumour of
the base; but I have never seen neuro-retinitis in these
cases save in syphilitic mischief. As to the frequency of
optic signs and their value in diagnosis I have nothing to
add to what I have said in previous sections. In my ex-
perience the optic signs have always been of late appearance.

Such are the facts concerning the ophthalmic signs of
intracranial tumours, so far as we know them. No one ad-
mits more readily than I do how few these facts are, and how
difficult it is to build up anything upon them. Taking
the chapter as a whole, the reader has seen that the occur-
rence of optic signs is so uncertain that the ophthalmoscope
will give no encouragement to the practitioner who takes to
it in the hope of making careful thought and quick sense
unnecessary. On the other hand, its revelations in many
cases are of the greatest value and importance, and in some
may even determine a diagnosis. If the subject is to
be successfully followed up, it must be by the addition of
large numbers of carefully observed autopsies, by the avoid-
ance of those reckless assertions of the certainty of ophthal-
moscopic indications in which too many writers have indulged,
and by the avoidance also of such smooth phrases as ( the pro-
pagation of irritation by a foreign body on the brain along the
course of the optic nerve/ and the like. There is little evidence
that tumours do propagate ' irritation ' in this way, and my
own pathological observations seem rather to prove the contrary.
I have not argued in the preceding section from any cases,
however clear they seemed to be, in which I failed to obtain
an autopsy ; and I hope that in all future examinations especial
attention will be given to the state of the nerve matter sur-
rounding the tumour. Softening and pressure I have found,
but not extensive proliferation strolling along devious tracts.
There is no mysterious liability in the optic nerves to symp-

N

178 OPHTHALMOSCOPE IN [CHAP.

tomatic change which is not possessed in a degree by all
others ; the frequent affection of the optic nerve being due
simply to its greater extent in the cranium, to its richness
in vascular and connective tissue, and to the size and position
of its centres.

IX. ATHEROMA, SOFTENING AND HEMORRHAGE.

In cases of recent haemorrhage, taken simply, we have but
little need for the ophthalmoscope. In a few cases of heavy
effusion I have seen a certain amount of venous distension in
the retina, either with or without some slight serous effusion
also. M. Bouchut gives a number of cases of haemorrhage,
and speaks of such changes in the disk as being very frequent.
The cases are by no means satisfactory ones. In many there
was no autopsy, and in investigations of the present kind,
cases without autopsies are really without value. In Case 74
(loc. cit.), indeed, the author actually reverses his proper attitude
and diagnoses an apoplexy on the strength of the optic signs.
In other cases where ^ an autopsy was made, no account is
given of the state of the kidneys. In one or two instances,
M. Bouchut's descriptions of the signs in the eyes are very
suggestive to me of the first stage of retinitis albuminurica,
a condition very likely to appear in such subjects. As an
example of the misleading of cases not controlled by autopsy,
I may refer to a case published by Dr. Kelly in the ' Lancet '
for Oct. 1 6, 1869. In this case a clot in the left hemisphere
close to the optic thalamus was followed by meningitis, and
abundant lymph was found at the base. There was also ven-
tricular dropsy. If the mirror had been used, no doubt
changes would have been found in the disks, and might
have been quoted as significant of haemorrhage. In this
part of his book, as elsewhere, M. Bouchut has allowed his
enthusiasm to get the better of his reason and his accuracy.
It would have been at least desirable to state in every case
whether albumen was present in the urine or not.

Dr. Hughlings Jackson's opinion on this point coincides so
nearly with my own, that I am able to have the advantage

v.] INTRACRANIAL DISORDERS. 179

of expressing my own opinion in his words. He says 59 :
' In this case, as in most cases of cerebral haemorrhage I
have seen, there were no abnormal ophthalmoscopic appear-
ances, although the clot was a large one. It has been
supposed by some, that large cerebral hsBmorrhage leads
quickly to acute changes in the optic nerves which, if the
patient lives long enough, end in atrophy. Now, whilst
admitting that optic neuritis does occur from clot, as it
does from other sorts of foreign bodies within the brain,
the association is a rare one, and the changes are never
seen soon a few days let us say after the effusion, never
during the stage of insensibility. I have once seen signs
of inflammation of the optic nerves in a patient who died
in a few days of clot 60 , but this was the exception proving the
rule, as the man had had a former attack of cerebral haemor-
rhage, and the defect of sight followed six months after
this, and twelve months before the fatal seizure. The
patient had been under Mr. Hutchinson's care for optic
neuritis. Optic neuritis from coarse intracranial disease
requires time for its production. Indeed, the proof of this
is best supplied by cases of cerebral haemorrhage, as we
know the exact time when the "foreign body" is established
in them and not in cases of cerebral tumours. When
optic neuritis comes on some time after a clot, we cannot
suppose that it has led by " gradual pressure" to inter-
ference with the optic nerves. I have once, in a case of
extensive meningeal haemorrhage (which I saw in a patient
at the Hospital for the Epileptic and Paralysed, under
the care of Dr. Ramskill, who is my colleague there as
well as at the London Hospital), seen extreme dilatation
of the retinal veins, but in most cases of cerebral haemor-
rhage I have found nothing to call abnormal 61 .

' In cases of large cerebral haemorrhage where there is
retinal disease with Bright's disease, there are usually (?)

59 London Hospital Keports,' vol. iv. 1867, p. 345.

60 See Royal Lond. Ophth. Hosp. Reports,' vol. iv. pt. iv. p. 435.

61 The pressure of a haemorrhage is not sufficiently prolonged to bring about
the gradual choking of the disks which we see in tumour.

N a

180 OPHTHALMOSCOPE IN [CHAP.

small haemorrhages about the disks, but so there are in
patients similarly unsound when there is no cerebral haemor-
rhage, and when the patient does not complain of his sight
and can read small print. Yet in the former they are perhaps
of larger size and more numerous. I scarcely think it likely
that these are due to suddenly added intracranial pressure,
but rather that, from some unknown reason, the whole of
the cerebral vessels are ready to break, and they break in
several places nearly at the same time.'

Such are Dr. Hughlings Jackson's opinions, and such also
are the results of my own experience. There are no doubt
certain cases where optic neuritis, or more probably atrophy,
has followed an encephalic haemorrhage after the lapse of
some or many months, but in these cases the haemorrhage
is but the indirect cause of a change which depends on like
changes in the brain mass which surrounds the clot. The clot,
or the nerve matter round it, or both, take on a cicatricial
change, and so gradually involve the nerve in a cicatricial or
sclerotic process. I have never verified this chain of events
by an autopsy, but Quaglino says, that in one case amaurosis
was found to have been caused by a cicatricial mass replacing
a clot which almost entirely replaced the right thalamus.
On the left side was found a recent extravasation of blood
which was not the cause of the atrophy discovered in the eye.
Dr. Hughlings Jackson has also recorded a case in which
clot of the left middle lobe, with small extravasations in the
tubercular quadrigemina, caused even descending neuritis.
This must have been through the means of irritation of the
sheath of the nerve.

Haemorrhage into the retina has been recorded in several
cases of encephalic haemorrhage, but I am not disposed to
think that any pressure upon the recurrent vessels could
burst the veins of the retina unless these were themselves
conspirators. In fact, retinal haemorrhages, independent of
albuminuric retinitis, are not uncommon in old people in
whom there is no cerebral haemorrhage and in whom there
may be none. Dr. Sands of New York has published a very
interesting case (quoted in 'Edin. Med. Journal,' 1868, p.

v.] INTRACRANIAL DISORDERS. 181

670), in which a haemorrhage into the sheath of the optic
nerve was supposed to be the cause of blindness, neuritis, and
atrophy. If such a sequence were verified at an autopsy, we
should have gained the certain knowledge that a clot can and
does excite inflammation in surrounding nerve tissue where
this is rich in connective tissue. I have certainly seen clots
excite meningitis ; and they might thus indirectly cause
amaurosis. A similar case is related most carefully in
Pagenstecher's ' Beobachtungen,' i. 54. Retinal haemor-
rhage I have seen several times among Mr. Teale's patients,
and I saw it in the case of a patient of my own, who
died three years afterwards of apoplexy. Both accidents
were said to be determined by a strain-; the dimness of
vision and retinal haemorrhage occurred suddenly while
he was dragging on a Wellington boot, and the apoplexy
occurred apparently in consequence of a muscular effort for
another purpose which he had allowed himself to make in
spite of warning. The patient was an old gentleman of
gouty habit, and with diseased arteries, but not afflicted with
kidney disease. Sometimes a small clot is thrown out upon
the optic nerves, and compresses them directly, as in Case
No. 71 in the Appendix. There are many more cases on
record of amaurosis coincident with apoplexy, but the absence
or insufficiency of post-mortem notes prevents my making use
of them.

The frequent concurrence of albuminuric retinitis and
encephalic haemorrhage in the same person is, however, reason
enough to urge us to examine the retina in all cases of en-
cephalic haemorrhage. The discovery of retinitis or its traces
should make us give a far graver opinion than in a case where
there was no degeneration of the kidney, and a somewhat
graver diagnosis than in cases where albumen in the urine
existed without retinitis. It may be the chances of individual
experience which lead me to say this, but it has certainly
happened to me very often to see retinitis in apoplectics who
have been rapidly cut off by a second attack, while others
having albuminuria but not retinitis have survived much
longer. I may extend this remark further, and say that I

182 OPHTHALMOSCOPE IN [CHAP.

believe a person who has not suffered from apoplexy but who
has retinitis is in great danger, though in adding this I am
going beyond my present subject. Perhaps I am not exceed-
ing my limits, however, in calling attention to a disorder of
vision, not attended with visible change in the eye, which is
often to be noticed in patients suffering from a mesocephalic
haemorrhage (see, e. g. Zagorski's case, App. No. 75). This
disorder is hemiopia, and depends, no doubt, on the distending
pressure of the clot upon one optic tract, for it passes off with
the absorption of the effusion. Such patients have satis-
factory central vision, but they may be seen to hesitate and
grope after objects lying on one side, the dark side of course
being the side opposite to the hemiplegia. This functional
disorder, for it seems never to advance to atrophy, may
remain for some time and be troublesome, but I think it
always disappears as the pressure is ultimately removed 62 .

There is another change I have often seen in the eyes of
those struck down with haemorrhage, and that is a certain
degree of nerve atrophy. This atrophy is more than mere
senile pallor of the disks, it is an actual though incomplete
atrophy, and is attended with some degree of loss of vision,
though this may not be sufficient to demand serious atten-
tion. The disks look white and diminished, and the vessels
are fine. I have not been able to ascertain the state of the
field of vision in these cases, but this would be an important
addition to our knowledge if obtained. I believe that the
atrophy is due to atheroma of the encephalic arteries, and
thus it may in some degree be recognized as a sign of athe-
roma and as a forerunner of apoplexy 63 . If this opinion be
confirmed, the sign would have a certain importance, when

62 Since this was written, I have met with some observations by Grafe on
the same symptom, and I find from a case of his which I quote in the
Appendix (p. 248), that the hemiopia was persistent, and atrophy of the
lateral halves of the nerves set in at last, though for five months no such
change was detected.

58 It is quite possible that a rigid artery, such as the posterior communi-
cating, might compress the optic nerve and strangulate it. This is a pure
hypothesis, however, for I am not aware that such an event has ever been
demonstrated.

v.] INTRACRANIAL DISORDERS. 183

taken with other things. I have published cases illustrative
of this at various times (see, for instance, 'Brit. Med. Journal,'
June 20, 1868), but as the confirmation of the rule must depend
upon other observers, no good purpose would be served by
reprinting them, the proposition itself being too simple to
need illustration.

The curious discovery by Charcot of miliary aneurisms in
the encephalon, which infest the parts subject to haemorrhage,
and which seem, in many cases at least, to be the immediate
cause of the haemorrhage, suggested to me, and to many
others, no doubt, the duty of searching for such aneurisms in
the eye. My own search was fruitless enough; but I find
from the Bulletin of the Academic des Sciences, in the
'Archives Generates de Medecine' (April, 1870, p. 503), that
M. Henri Lionville has been more successful. He appears
to have noted the coexistence of miliary aneurisms in the eye
and in the encephalon so early as 1868. He now describes
the case of a patient, aged 72, who died in the Salpetriere
after several small apoplexies. Innumerable miliary aneur-
isms were found in the brain, the cerebellum, the pons, and
the membranes. There were also aneurisms in both retinas,
which latter lesions corresponded to small haemorrhages in the
retinal layers. Examined under the microscope, these aneurisms
presented a marked likeness to the changes of the same kind
in the encephalic vessels. The report does not say whether
these aneurisms were discovered by the mirror ; apparently,
they were not found until the post-mortem examination.

If we leave recent apoplexies, and turn to ancient ones, we
are no longer in want of curious ophthalmic signs. It is a
very remarkable and interesting fact that old clots do often
give rise to both neuro-retinitis and atrophy, though it is
very uncertain how this comes about (vide Cases 72, 73, 74, 76
in the Appendix). Of course it is easy to set neuritis down to
'irritation' propagated by a ' foreign body ' lying long in
the brain ; but we have very little evidence in favour of our
accepting this explanation in its only intelligible sense, in the
sense that it is a creeping proliferative process. If this be
not the explanation I have certainly no other to offer ; but in

184 OPHTHALMOSCOPE IN [CHAP.

the only two cases in which I had an opportunity of examin-
ing an old clot, I found nothing to support the hypothesis.
In one case there were the remains of an old clot in the right
posterior cerebral lobe ; in the other the remains were in the
left corpus striatum. In both cases the clots must originally
have been as large as a walnut ; and there was in each case
a distinct history of an antecedent apoplexy, which in the
former case happened a year before, in the latter eighteen
months. There was no amaurosis in either case. In both
there was a somewhat hardened lump in the brain, faint-
reddish brown in the centre, and dying off through ochrey
and lighter colours at the circumference, where the lumps
faded gradually into normal brain tissue. The lumps pre-
sented the microscopical characters common to such remains,
and in a small belt of brain matter, of perhaps half an inch
in diameter, I found an absence of proper tissue, and a
presence of connective, degenerative and crystalline elements.
I could not, however, in either case find evidence of extensive
sclerosis passing to a distance. Still, if secondary sclerosis
be not the link between amaurosis and old haemorrhage
occupying parts outside the actual parts of vision, I am at
a loss to suggest any other.

Embolism does not give rise to any definite eye mischief, so far
as I know, unless it be followed by extensive central softening.
The contrary is stated by some writers, and I myself thought
it likely that immediately after the accident, when the
internal carotid was propelling blood over an area suddenly
diminished, there might be some evidence of increased arterial
tension, either in dilated vessels or in some degree of effusion.
In one or two cases I have noticed some degree of haziness
about the borders of the disk and vessels, but nothing that I
could with a good conscience call a distinctly morbid state.
The phenomena of embolism will, however, be discussed again
in a subsequent chapter.

Softening of parts of the- encephalon other than the optic
centres, tracts, or nerves, without sclerosis, is not attended with
any significant changes in the eye. Amaurosis would no doubt
result from destruction of the visual centres, or from haemor-

v.] INTRAGRANIAL DISORDERS. 185

rhage into them, but I have never been able to satisfy myself
of such an occurrence by post-mortem examination. Several
such occurrences are, however, on record, the morbid event in
the eye being primary atrophy of the disks, following loss of
vision. Atrophy also coincides with a certain farther number
of cases of central softening ; in some it is incomplete, and is
probably due, like the softening itself, to atheroma of the
vessels ; in others, however, it is progressive and unmistake-
able, when it is probably due to the including of the nervous
parts of vision in the central degeneration. Many such cases
are recorded by Lancereaux and other writers 64 ; but the optic
changes occur very capriciously, and have not in their cha-
racter or mode of occurrence anything sufficiently significant
to make it worth our while to discuss them at any greater
length (vide Cases 68, 69, 70 in the Appendix). Certainly
softening may be present, and often is present in much
of the encephalon, without affecting the optic disks in the
least, but it can scarcely cut them off from their trophic
centre without destroying them. In one very interesting
and well-reported case quoted in the Appendix (No. 69),
neuro-retinitis undoubtedly accompanied what looked like
rapid softening, but may have been encephalitis. I do not
know how to explain the neuro-retinitis in this rare case. The
optic nerves and centres were not noted after death, nor is the
state of the membranes mentioned.

Why in some cases softening involves the nervous parts of
vision, and in others does not do so, is hard to say ; but it
progresses in two different ways at least : first, in arterial
regions; secondly, by contiguity, as does gangrene of other
organs. Here, however, as elsewhere, when we seek to know
where filaments or cells of vision are first involved, we are at a
loss for a really sound anatomical basis upon which to work.

64 See, for example, a case under Dr. Sibson, in the ' Pathol. Proc.' No. 6,
p. 462. Amaurosis accompanied other evidences of widespread intracranial
mischief. At the autopsy extensive softening was found without signs of
proliferating action, the sheaths of the vessels being, if anything, fatty. The
mirror was not in use in 1852 ; but I am surprised that no mention is made of
the state in which the optic nerves and other parts of vision were found after
death.

186 OPHTHALMOSCOPE IN [CHAP.

X. CEREBRITIS, ABSCESS, SCLEROSIS.

The chapter on Cerebritis in Reynolds's ' System of Medi-
cine ' reminds us of the celebrated chapter on Snakes in Ire-
land : there is no such thing as cerebritis, the accomplished
authors themselves having done the work of St. Patrick.
Nothing could be more necessary or more successful than the
destructive onslaught of Dr. Reynolds and Dr. Bastian upon
the pretensions of all sorts of degenerations in the encephalic
mass to call themselves inflammations; but pathologists can
scarcely admit that no process whatever exists which can
rightly be classed with the inflammations of other organs.
The interesting lectures on Analytical Pathology lately
published by Dr. Moxon set forth very clearly a result at
which we were all arriving, namely, that two chief kinds of
' inflammation ' may be classified separately as free inflamma-
tions and interstitial inflammations, each class having many
peculiar characteristics. Any process, like inflammation,
occurring in the encephalic mass, must have the characters of
the interstitial kind ; it must be like interstitial pneumonia,
not like exudative or epithelial pneumonia ; it must be like
keratitis, not like conjunctivitis ; it must consist, that is, in
the proliferation o"f connective elements, not in the proliferation
of epithelial or free elements. That the connective element
exists scantily and obscurely in the encephalon, makes a great
difference in degree between its reaction under irritation and
the same reaction in other parts which, like the optic nerve or
the lung, are rich in connective elements; but it makes no
difference in kind. Interstitial cerebritis is as definite a
process as interstitial hepatitis or interstitial nephritis, but
it is more difficult to demonstrate, and arises less easily.
That the encephalon, as a whole, is certainly not a susceptible
organ not very susceptible, that is, to common irritations
depends mainly upon this poorness of it in the undifferentiated
tissues and its richness in tissues which are highly specialized.
These highly specialized tissues are as little able to respond
by proliferation to simple lesions as a highly specialized

v.] INTRACRANIAL DISORDERS. 187

animal to reproduce an amputated claw. Moreover, we must
remember that our observations are as yet very incomplete.
The number of instances in which the brain tissue around any
irritant has been minutely examined, with a view to esti-
mate the secondary proliferation, are as yet very few. For
several years I have been hoping to obtain an autopsy in some
case of optic neuritis connected with encephalic abscess, and
unconnected with meningitis, in order to ascertain whether
the neuritis is continuous with a cerebritis propagated from
the walls of the abscess, but I have failed. Here again I
have to confess to one more of the hiatus valde deflendi which
make me doubtful of my right to publish my labours at all.
I have twice had the opportunity of examining abscess of the
brain from cases in which no examination of the disks had
taken place ; in neither case did I see the patient alive or dead,
nor were the optic nerves forwarded to me. In one case the
abscess was encysted, and all evidence of irritation ceased within
a short distance of its boundaries ; in the second case, the
abscess was not encysted, and the evidences of irritation were
well marked and widely diffused.

The new fibroid elements and cells penetrated the tissues in
many directions, and were best seen in the fresh state. The
vessels showed the greatest activity, the sheaths and coats
being the seats of an abundant proliferation. No doubt a
considerable number of emigrant leucocytes may have been
present likewise, and I cannot pretend to be able to distin-
guish them from young connective corpuscles ; but there was
an appearance of nuclear activity around the vessels which
must have given rise to a considerable proportion of the new
elements. As the abscess was approached, the new elements
became more evidently what we call pus, and there was a
more complete breaking up and liquefaction of the proper
tissue of the anterior lobe of the hemisphere in which the
abscess occurred. The abscess followed a blow upon the head,
but there was no meningitis to be seen. Now, it must be
remembered, that a very few elements in this state of high
irritation, if they penetrated so far as the optic nerves or
tracts, would be competent to set up by continuity a. like

188 OPHTHALMOSCOPE IN [CHAP.

process in them; the evidence of irritation becoming then
more intense and vigorous as the optic nerves are more
vascular and richer in connective tissue. By the penetration
of a spark to a more inflammable tissue, the smouldering in
the brain is lighted up afresh in the optic nerves. Or if the
process be more chronic, if the original focus of irritation be
the remains of a blood-clot rather than a lacerated portion of
healthy brain, or if it be an old pyaemic settlement, we shall
see, instead of a red sclerosis, a white sclerosis, a primary
atrophy instead of a neuro-retinitis. Sclerosis occurring in
this way may be called propagated sclerosis, to distinguish it
from insular sclerosis, in which the disease fixes with apparent
caprice upon this part or that, without passing along any
perceptible routes. M. Hayem, in a very interesting paper
contributed to Brown- Sequard's ' Archives de Physiologic
Norm, et Path. 5 (vol. i. p. 401), describes the results of some
experiments performed by him in Vulpian's laboratory, to
ascertain the way in which abscess in the brain is set up.
M. Hayem inflicted injuries upon the brain in guinea-pigs,
allowed reaction to take place, and then examined the parts after
death. M. Hayem found, in cases where a sufficient time had
elapsed, that very active proliferation in the neuroglia and
in the connective tissue about the vessels took place, and that
the formation of cerebral abscess differed in no respect from its
formation in other organs. He believes that new blood-vessels
also appear in some number. The appearances of cell activity
presented a remarkable difference from the like parts breaking
down beyond an embolism. In one of his cases he obtained
an encysted abscess ; and in another, the abscess underwent
the caseous transformation.

Abscess, I conceive, may act in three ways upon circum-
ambient nervous tissue : it may involve itself in a cyst, and
leave the tissues without the cyst unaffected, or nearly so ; it
may, if not encysted, penetrate into the surrounding tissue
for a considerable distance, setting up proliferation in the
neuroglia and in the sheaths of the vessels, with liquefaction
of the nerve elements; and, thirdly, it may, whether encysted
or not, cause those bands of secondary degeneration studied

v.] INTRACRANIAL DISORDERS. 189

by Tiirck, which are not easily produced by direct experiment,
but which are gradually effected by the fell patience of
disease 65 . How susceptible the brain is in some states to a
distinct and complete inflammation, is proved by the remark-
able encephalitis of young children first discovered by Virchow,
and since abundantly confirmed by others. In these cases the
whole encephalon is in a state of ' neuritis/ the proper tissue
being crushed out by an enormous and universal hyperplasia
of the neuroglia. I am not aware that any observations of the
optic disk have been made in these cases. Still, this shows of
what the brain is. capable, and how optic neuritis may result
from a similar process set up by such an irritant as a bony
thorn, an old clot, an abscess, and the like. The observations
of Dr. Hughlings Jackson, published in the fourth volume of
the ' London Hospital Reports/ certainly prove that ( optic
neuritis ' is common as a consequence of abscess, whatever
the intermediation may be. Two of his cases are especially
interesting (Nos. xxv and xxvi). In xxv, an abscess the size
of two walnuts lay near the central parts of vision; the
mirror revealed ' a state of neuritis.' The disk was obscured
by a large patch, and its position known only by the con-
vergence of vessels. The arteries were only visible at the very
point of convergence. The veins were large and irregular;
patches of blood were scattered about, as if on and smearing
a white ground. The diseased patch was about three times
the diameter of a normal disk. Both eyes were nearly alike
(loc. cit. p. 383). Clearly it was a case of neuro-retinitis, with
the haemorrhagic characters I allude to on page 61. At the
autopsy there was no meningitis of the base. The parts about
the abscess were sent to Dr. Lockhart Clarke, but by a sad
misfortune were thrown away. Had they been examined, we
should certainly have learnt the answer to the great ques-
tion May neuritis descendens be due to a creeping prolifera-
tion taking origin in the brain tissue round about a foreign
body ? We still await the reply.

If the abscess be accompanied, as abscesses secondary to

65 Dr. Charlton Bastian has described this condition as consecutive to a
haemorrhage, in the fiftieth volume of the ' Medico-Chirurgical Transactions.'

190 OPHTHALMOSCOPE IN [CHAP.

disease of the nose or ear so commonly are accompanied, by
meningitis of the base, then we have a known cause of de-
scending 1 neuritis, a cause which I have repeatedly proved.
Then, as I have said (page 85 et seq.), we can demonstrate
the creeping of the proliferation from the membranes upon
the optic neurilemmata. Traumatic meningitis, so often on
the convex surface, can scarcely be the missing link in the
cases of abscess with neuritis following a blow.

If an abscess, encysted and not setting up circumambient
irritation, press upon the central parts of vision, obliterate
the optic nerves, or set up tracts of secondary degeneration,
I suppose that atrophy of the disks would be the more or less
remote consequence ; but I am not aware of any instance in
which such an observation has been verified. Nor am I
aware of any case in which simple choking of the disks
(ischtemia) has resulted from the presence of abscess. An
ordinary abscess indeed would scarcely raise the tension of the
encephalon to any marked degree, though it certainly might
do so if there was a rapid cell growth, or a rapid accumulation
of emigrant leucocytes.

It is clear that the irritation or encephalitis set up around
1 foreign bodies ' is no different in kind from primary sclerosis ;
'encephalitis,' ' cerebritis,' 'sclerosis,' 'cirrhosis' 7ro'AA.o>i> ovopd-
T&V /u.op<r/ fjiia may differ in rate, but they are all alike in
genesis, or rather in mode. In genesis there is probably a differ-
ence between one kind of sclerosis and another. The causes can
hardly be the same which give rise to infantile encephalitis,
and to insular sclerosis, for example; or, to press matters
nearer still, the sclerosis which involves the whole of an optic
nerve, and is the result of some distant irritative process closing
in upon it, must have a different kind of origin, one would
think, from that sclerosis which does not close in upon the nerve
in a uniform way, but which exhibits itself upon the nerve in
several isolated patches. This latter event belongs to some
cause far wider in its action, something which affects the
whole cerebro-spinal axis from the optic disks to the cauda
equina, and perhaps the organic nervous centres also. In a
more diffuse form in general paralysis, in ribbon-like tracts

v.] INTRACRANIAL DISORDERS. 191

or bands in locomotor ataxy, and some cases of disease
of the anterior columns, or in insular patches, as in scle-
rosis with palsy, may this fatal change invade the nervous
system, its clinical results varying according to its seat rather
than according to its nature. All that I may do now is to
point out that no part of the nervous system is more obnoxious
to this process than are the optic nerves, so that optic atrophy
is a common concurrent, and not an uncommon antecedent in
these cases. Under General Paralysis I shall show that
atrophy of the disks forms an integral part of the disease;
and that it forms a part of locomotor ataxy, is familiar to
every one.

Finally, in insular sclerosis, or sclerosis with palsy and
tremor, we find the same primary atrophy of the disks, an
event which may occur very early in the series of symptoms,
or may set in somewhat later. As I have frequently hinted,
this liability of the optic nerves may be due to their richness
in vessels and in connective tissue ; but however this may be,
a slow initiation of palsy of the legs, together with atrophy
of the optic disks, would lead me strongly to suspect the
hidden cause to be insular sclerosis.

To speak even more generally, I have three cases now in
my mind, which I do not record because I have had no
autopsy in any of them, but in which amaurosis due to
atrophy of the optic disks certainly long preceded other
manifestations of the three kinds of sclerosis I have men-
tioned. One man, who attended for some time at Mr. Teale's
clinic for amaurosis, and of whom I lost sight, turned up
again, a general paralytic, in the West Riding Asylum ; the
second fell a victim to locomotor ataxy; and the third is
now developing symptoms strongly suggestive of palsy with
tremor 66 .

I have had no autopsy in any case of my own affected with

66 This man (George Airey) now presents symptoms of insular sclerosis
which scarcely admit of question. He has been under my care as an out-
patient for three years with atrophy of the optic disks, gradual loss of power
in the limbs, and tremor on voluntary movement. I do not publish the case
at present, as the diagnosis cannot be called quite certain without an autopsy.

192 OPHTHALMOSCOPE IN [CHAP.

insular sclerosis, but the parts from such a case were sent to
me about a year ago by my friend Dr. Crichton Browne. The
appearances in this case must be described elsewhere ; but as
regards the optic nerves, I found them in many places reduced
to mere connective tissue, with scarcely a trace of nerve fibre.
The process was not uniform, but showed harder and whiter
patches in places ; so that by preserving such parts of the
nerves as were not examined, in a small glass tube, I was able
to demonstrate to the eye the partial characters of the mis-
chief. I would urge all practitioners, then, whether surgeons or
physicians, to avoid speaking too lightly of the consequences
of atrophy of the optic disks ; if this amaurosis be not as
certainly of ill omen as a like discovery of albuminuric reti-
nitis, it nevertheless is but too probable that it may be the
first manifestation of some form of sclerosis. Although no
wise man would set up unnecessary alarm in the minds of
patients or their friends, yet it is his duty to avoid any con-
trary assurances of safety. We shall do well to remember how
such cases may turn out, and to keep such patients under our
observation.

In concluding this section, let me warn the reader not to
confound with this primary sclerosis a secondary form, which
springs up as a result or consequence of nerve wasting. If
the fibres, for instance, of the optic nerve waste for any reason,
say on account of some disconnection from their centres, then
the tendency is seen in connective tissue to replace them.
It is fed perhaps on the food set free by the removal of the
nerves. However this may be, such hypertrophy is sometimes
mistaken for primary sclerosis, and was so mistaken by myself
for some time. During this time I was constantly puzzled
by observing that in some sections of such optic nerves the
nerve fibres wonderfully retained some sort of continuity in
spite of great overgrowth of the connective tissue ; while in
other cases the nerve fibres had fled evidently before the con-
nective tissue could have made any serious encroachments.
The former state is seen in primary sclerosis; the latter is
seen when the nerve fibres waste from some other cause, and
are replaced by an interstitial hypertrophy. Unfortunately I

v.] INTRACRANIAL DISORDERS. 193

know of no means of distinguishing the two processes by the
mirror. The distinction between atrophies with white, large
chalky disks and those with shrunken grey disks does not
seem to correspond to any constant or essential difference.

XI. GENERAL PARALYSIS.

As I held that disease of the encephalic vessels was a
common cause of atrophy of the optic disks, I entered upon a
series of investigations into the state of these parts in general
paralysis. The results I obtained were published in the
1 Transactions of the Medical and Chirurgical Society' for
1868. I afterwards found that atrophy of the disks in general
paralysis had been noticed by Galezowski in one or two cases,
by Lancereaux also, and by Von Grafe, but none of these
authors seem to speak from any extended observation. About
the same time that I was inquiring into this matter, however,
Dr. Westphal, with Grafe's assistance, was similarly engaged
at Berlin, and a copy of his paper on the general progressive
paralysis of the insane was kindly sent to me by Dr. Jackson
after the publication of my own conclusions 67 . Although I
may venture to say that his researches were far less complete
than my own, yet it is satisfactory to find that our con-
clusions are the same. I shall proceed therefore to describe
what I myself have seen, without further reference to other
writers.

It is a very remarkable fact that in almost all cases of
general paralysis there is a tendency to atrophy of the optic
nerves. (Vide cases of G. P. in Appendix.) The change seems
sometimes to be one of simple atrophy, white from the begin-
ning; in other cases, and perhaps more commonly, the white
changes are preceded by a stage of redness, and the whole
process then resembles some cases of tobacco amaurosis, and
what I have called chronic neuritis 68 . The degenerative process

67 This valuable but cumbrously written paper appeared in Griesinger's
' Arch, fur Psychiatric,' &c. The reference to the number is not given upon
the separate impression, but the author's date is May, 1867.

68 Vide page 64, and the plate of disks in lead poisoning.

O

194 OPHTHALMOSCOPE IN [CHAP.

begins about the end of the first stage or the beginning of
the second, and not infrequently results in complete amau-
rosis. Probably in most cases of general paralysis great loss
of vision might be ascertained in the third stage, if such
patients were carefully watched.

The conclusions which I drew in the fifty-first volume
of the ' Medico-Chirurgical Transactions ' from the careful
examination of cases are reprinted in the Appendix, to which
the reader is referred for further details.

The pathological characters of the changes in the optic
nerves in these cases are a dwindling of the proper nerve
structures and an overgrowth of the connective tissue. Now
in what relation does this change stand to the brain changes
in general paralysis ? There are several possible explanations :
first, if luminous impressions are perceived in the cortical
matter of the hemispheres, it might be expected that as
the perceptive centres wasted in disease, so the optic nerves
would waste from disuse. This, I think, is Lancereaux^s view.
In wasting of the centres, however, it is not the afferent but
the efferent nerves which suffer ; and moreover, I have proved
by the microscope that if the disease in the optic nerves in
general paralysis be not centripetal, at any rate it is not
centrifugal, for the optic trunks are often far more diseased
than the tracts or corpora quadrigemina. Another explana-
tion, and that by which I was at first tempted into investi-
gation, is, that the degeneration of the optic nerves is due to
the atheroma of the vessels. (Vide page 182, of the present
volume.) But I think now that the explanation is to be
sought rather in the peculiarity of the primary morbid change
and in the anatomical characters of the tissues which it in-
vades. How comes this sclerosis or overgrowth of connective
tissue about ? Is it that some ' irritation/ say of a ' foreign
body ' or of a ' morbid state of the blood,' excites this tissue,
which then grows like thistles on stony ground and chokes
the good seed ? Or is it that the formative nisus is for some
reason insufficient to raise material up to the height of nerve
tissue, and can create only an inferior product? Or is it,
again, that the proper nerve tissue wastes, ceases somehow to

v.] INTRACRANIAL DISORDERS. 195

attract and use the blood which passes through the part, and
that the connective tissue then battens upon the blood, which
it now has to itself? This much it seems safe to say, that the
optic nerves are more liable to sclerosis than any other nerves 69 ,
which indeed we should expect from their vascularity and
richness in connective tissue ; and that the optic nerves may
suffer alone from sclerosis, this remaining the sole nervous
lesion, or turning out to be only a forerunner of diffused or
patchy sclerosis elsewhere in the brain, for instance, in the
pons, or in the cord. It seems quite certain (vide Charcot,
' Gaz. d. Hopitaux/ 1868, 1869) that, although 'sclerose en
plaques' occurs now here and now there, yet that it favours
certain parts, e. g. the optic nerves, more especially. The
reason of its occurrence in the optic nerves and in other parts
of the nervous system must in all likelihood be the same, and
depends either upon some disposition of the whole nervous
system to a peculiar irritation (' reiz '), or upon some state of
the blood, such as lithiasis, acting upon it as a whole.

I am somewhat surprised that in six cases of progressive
muscular atrophy, a disease which depends upon patches of
sclerosis in the centres, I have not found any degeneration of
the optic nerves. In one case, however, external strabismus
was an early symptom, and was due perhaps to sclerosis of the
third nerve 70 .

69 It has been noticed, however, both by myself and others in all the first
seven pairs of cranial nerves.

70 Vide section on Sclerosis, p. 186,

O 2

CHAPTER VI.i

ON THE OPHTHALMIC SIGNS OF DISEASE OF THE
SPINE.

THE curious connection of amaurosis with spinal disease,
and especially with, locomotor ataxy, has lately attracted much
interest. Some observers have endeavoured to explain the
concurrence by the hypothesis of an irritation or palsy of medi-
ating- vaso-motor nerves ; with what truth remains to be seen.
In the section on encephalic tumours I have discussed the
value of this hypothesis as offered in explanation of the optic
nerve changes which accompany such growths within the
skull, and I have shown to my own satisfaction that the
hypothesis has not the explaining power possessed by certain
other hypotheses. As regards the encephalon, however, the
admitted obscurity of the causation of optic disorders, and
our still greater ignorance of the arrangement and power
of any intracranial vasal nerves or centres, aid the reasoner
who would connect the two. Here are effects waiting for a
cause, and here is an unemployed cause waiting for attributed
effects; what could be better than to join the one to the
other ? In spinal disease, however, this simple and easy way
of writing nature down in a book is not so readily applied ;
for, unfortunately, here we have a few facts, and facts, when
they once appear, will grow up like weeds in the trimmest
gardens. We do know something about the attachments

1 A considerable part of this chapter was published in the ' Lancet' of
January 15, 1870.

THE OPHTHALMOSCOPE, $c. 197

and centres of vasal nerves in the cilio-spinal region and the
medulla; we have careful records of many cases in which
these nerves or their centres have been severed or irritated
by disease or by experimental injury, and we have notes of
certain tolerably uniform results which follow such diseases
or injuries. Whether among 1 them we find optic neuritis or
atrophy of the optic nerves, remains to be seen.

The facts we have to deal with here will be best discussed
in the following order :

Firstly. Do disturbances of the optic nerve and retina com-
monly follow spinal mischief?

Secondly. If so, then what kind of disturbances are they ?
And,

Thirdly. What reason or reasons can we assign for their
occurrence ?

Firstly, then, are the accounts of disturbance of the inner
eye secondary to spinal disturbance to be trusted ? Of this
there is little doubt : it is tolerably certain that disturbance
of the optic disk and its neighbourhood is seen to follow dis-
turbance of the spine with sufficient frequency and uniformity
to establish the probability of a causal relation between the
two events.

I myself examined and tabulated, from this point of view,
thirty well-marked cases of spinal injury; and in eight of these
I found secondary disturbance within the eye. Of these cases,
seventeen were severe injuries which proved fatal within a few
weeks, and in none of these did changes appear in the eye :
the remaining thirteen cases were of chronic spinal disease
following accidents of less severity, and it was amongst these
thirteen that I discovered the eight cases of concurrent dis-
order in the eye. Of acute myelitis I examined five cases,
and in one only did eye disorder supervene. This remark-
able case was of very long duration, and was followed by
partial recovery; in it disorder of the eye came on many
weeks (twelve or thirteen weeks at least), after the subsidence
of the acuter symptoms. The myelitis in all these five cases
was in the dorsal, or upper lumbar region. Of chronic dege-
nerations of the cord, exclusive of locomotor ataxy, I have

198 THE OPHTHALMOSCOPE [CHAP.

records of nine cases. In five of these marked changes in the
eye appeared 2 . In locomotor ataxy the occurrence of affection
of the optic nerve is so well known, that I think it scarcely
worth while to sum up my notes of this disease. I wish now
to make use of the three following conclusions in particular,
which my researches seem to indicate :

1 . That changes at the back of the eye do not infrequently
follow spinal disease.

2. That these " changes do not become established in the
cases which run a short course, but they slowly supervene in
the course of weeks or months in more chronic cases.

3. That in spinal disease arising from injury, the higher
the seat of the injury the sooner are there changes in the eye.
Of this last conclusion I have satisfied myself, after a careful
observation of well-marked cases. I have found that the optic
changes follow injury to the spine more rapidly if, for example,
the injury be in the upper cervical region than if it be in the
lower cervical or in the upper dorsal region. One of the best-
marked cases of eye disorder with spinal injury that has oc-
curred in my own practice, was in a man who had suffered an
injury to the spine in the region of the atlas and third cervical
vertebra. The injury was set up by a sudden twist of the
head backwards and to the left. In him changes at the back
of the eye appeared very quickly and decisively. The patient
is still living, but it was clear from the symptoms that the
lower cervical and upper dorsal regions were unaffected.

Having seen, then, that there are changes in the eye
symptomatic of spinal disease, our second inquiry is Of what
1 ind are these changes ? Confining ourselves to the optic
nerve and the retina with their vessels, and omitting all
reference to injection of the conjunctiva, or the state of the
pupil, what kind of changes are dependent upon disturbance
of the spine ? I find that they may be well classified under
two heads : (i) Simple or primary atrophy of the optic nerve,
sometimes accompanied at first by that slight hyperaemia and

2 The above numbers refer only to cases which I had watched and noted
carefully during a long period, ending January, 1870. A very much larger
number of cases have come before me in a more or less passing way.

vi.] IN DISEASES OF THE SPINE. 199

inactive proliferation which make up the state I have called
chronic neuritis. This sort of change I have never found
as a result of spinal injuries, but I have often met with it
in chronic degeneration of the cord and in locomotor ataxy.
(z) A somewhat characteristic hyperaemic change which I
have not seen in chronic degeneration or in locomotor ataxy,
but in cases of injury to the spine only. The retinal arteries
do not dilate, but become indistinguishable ; while the veins
begin to swell, and become somewhat dark and tortuous. The
disk then becomes uniformly reddened, and its borders are
lost, the redness or pinkness commencing with increased
fine vascularity at the inner border, which thence so invades
the white centre and the rest, that the disk is obscured, or its
situation known only by the convergence of the vessels 3 . In
many cases, rather than redness, I have observed a delicate
pink pink which sometimes passes into a daffodil colour.
In one case in particular a man at Elland who had been
injured in a railway accident and whom I examined in
consultation with my friend and colleague, Mr. Teale this
daffodil-colour of the whole field was very curious ; no disk
was to be distinguished, but the dark vessels stood out in
beautiful relief 4 . The other eye presented the more common
appearances of hypersemia and serous effusion, with slight
swelling. It is to be remarked, that this state is generally or
always of long duration ; it passes very slowly up to its full
development, and then shows a disposition to end in resolution
rather than in atrophy. In those cases which I have been
able to watch diligently for many months, the pinkness seems
slowly to have receded, leaving an indistinct but not very
abnormal disk behind. Sometimes the sight suffers a good
deal in these cases, sometimes but little or scarcely at all. I
have never seen true neuro-retinitis with active proliferation
as a sequel of spinal disease.

3 I need not say that -the disk has in reality no borders, but only ap-
parent borders, which are readily blotted out by any loss of transparency
in the retina.

4 I think these colours are due to the loss of retinal transparency and
the blending of its acquired reflections with those of the coats behind it.
The state is, I believe, an incomplete or a receding ischsemia papillae.

200 THE OPHTHALMOSCOPE [CHAP.

The third and most difficult inquiry now remains What
is the reason of the occurrence of these symptomatic changes ;
what are the processes which, following the changes in
the spine and preceding the changes in the eye, link the
two events together in the chain of causation ? One answer
has been lately offered to this question by a distinguished
physiologist, Mr. Wharton Jones. His argument is, that
when the cord is injured, the sympathetic nerve or its origins
are involved ; and that, as the sympathetic nerves govern
blood-vessels, and blood-vessels govern nutrition, therefore the
changes in the nutrition of the eye are due to irritation of
the sympathetic, which cuts off arterial blood from the optic
nerve, or to the palsy of it, which deluges the nerve with
blood. Mr. Jones, indeed, speaks as if dilatation of the arteries
at and about the disk were a matter of direct observation.
I must say, after some experience with the ophthalmoscope
in cerebro-spinal diseases, that this phenomenon has hitherto
escaped me. A really satisfactory explanation of the concur-
rence of spinal and ophthalmic disorders cannot, in truth, be
given, until a far greater number of observers have been at
work, and until careful autopsies have been made in such
cases, with minute examination of the nervous tracts and
centres. Meanwhile, no doubt, we must deal more or less in
conjecture. The objections to the sympathetic-nerve theory,
however, are manifold. The theory is not a new one, and in
the chapter on the ophthalmoscopic symptoms of intracranial
tumours (p. 119 et seq.), I have already pointed out objections
to it which seem fatal. Certain changes said to occur in the
fundus in Graves' disease are sometimes called in evidence to
show that a diseased sympathetic causes retinal disorder. It
is not yet proved that disease of the cervical sympathetic is the
secret of Graves' disease ; and were it so, the changes in the
retina have yet to be determined. I will quote one record of
such so-called retinal changes, from an eminent writer who shall
be nameless : ' The retinas were observed to be of a bright red
colour from injection of the vessels; also on each side of the
optic papilla, pigment was deposited in semilunar masses almost
black in hue.' This description is absurd, and yet it was not

vi.] IN DISEASES OF THE SPINE. 201

only pressed into use as an argument in favour of sympathetic
nerve causation in exophthalmos, but it was also adduced as a
parallel to like pigmentary changes in disease of the supra-
renal capsules, which therefore must again be of sympathetic
origin !

In the first place, to call up the sympathetic system is
to call up too potent an agency for the pressing difficulty.
Are we to suppose that the irritated sympathetic causes the
destruction of all connected parts ; or that it starves the optic
nerve by preference, while it leaves all other parts in its dis-
trict unaffected ? Or can a palsied sympathetic be the ruin of
the optic disk, when its effects are unseen in the pupil, unseen
in the conjunctiva, unseen in the ear and cheek? On the
other hand, it is a matter of verified observation, in numerous
cases in which there have been most obvious signs of a palsied
sympathetic in the ear, face, and outer eye, that in these very
cases the back of the eye has been found unchanged. Such
is the teaching of Dr. William Ogle's case, read before the
Medical and Chirurgical Society on the 23rd of March, 1869;
and I have a case which is equally instructive in another way
under my own care at present. In this little boy, ' a blow
upon the nape has set up " strumous" mischief in the cervical
portion of the spinal column, with consequent palsy of the
arms and legs. During the last few weeks, owing, no doubt,
to a lateral extension of the mischief, the left sympathetic
in the neck has also become involved, and we have the well-
known signs in the left face, namely, narrowed palpebral
aperture, injected conjunctiva, undilatable pupil, flushed cheek
and ear, and temperature of the cheek ranging from 5 to 9
above the right cheek, except during a febrile access, when
this difference ceases or is diminished/ Now in this patient
the symptoms of concurrent disorder of the optic nerve and
retina were observed in both eyes many weeks before the
affection of the cervical sympathetic occurred ; the changes in
the eye being of the second kind mentioned above, namely,
hypersemia, with serous exudation; and there has been no
change in the left disk, or in either disk, since the affection
of the sympathetic.

202 THE OPHTHALMOSCOPE [CHAP.

Dr. Hughlings Jackson has come to conclusions resembling-
my own, and I shall therefore quote here an important passage
of his bearing on the present subject. It is extracted from
the ( Medical Times and Gazette' of October 3, 1863. This
skilful observer says :

' I have examined the retina in a case of wound of the spinal
cord, in which there were on the left side symptoms like those
following section of the cervical sympathetic, but I could not
find the least difference in the size of the vessels or in the
colour of the optic disks, both eyes being under the influence
of atropine ; besides, there was not, nor had there ever been,
any defect of sight whatever.

' I have had under my care a case of neuralgia of one side
of the face, with contraction of the pupil and slight ptosis.
As there was, as well as the contraction of the pupil, con-
siderable narrowing of the ocular aperture, it looked, so far,
like a case of paralysis of the cervical sympathetic; and as
there was neuralgia on the same side in most of the branches
of the fifth nerve and hypersesthesia to the touch, and as the
least exertion made the patient sweat on the affected side,
this opinion seemed confirmed. The affection was, I consider,
in its mechanism, so to speak, I do not say in its cause, a sort
of miniature herpes zoster. There was the neuralgic pain, but
the changes of nutrition were represented only by a slight
haste of the natural functions of the skin, and not by the
uproar of actual inflammation. There was something more
than paralysis of the branches of the sympathetic correlated
with the sensitive nerves to the iris and face, as section of the
sympathetic does not produce neuralgia, but this paralysis
was, I believe, one link in the chain. Although the pupil was
only one-third the size of the other, there was no defect of
sight whatever. I did not look for defects of sight because
the pupil was contracted, but because there might be changes
in the retina similar to those in the iris. The patient could
read small print easily, and could also see well in the distance.
He had no dimness of sight, no " clouds," " colours," " specks,"
&c., and not a trace of intolerance of light. He could bear,
he said, to look at the fire without any annoyance. I dilated

vi.] IN DISEASES OF THE SPINE. 203

the pupil by atropine, and made an ophthalmoscopic examina-
tion. I found no signs of vascularity, the optic disks being as
as nearly alike as possible. If there were any difference, it was
that the disk on the affected side was slightly less coloured
than the other. This examination was made soon after the
pain had begun, but I examined again a few months after-
wards on a relapse of the pain ; the pupil being still con-
tracted, I again used atropine. The disks were then quite
alike in every respect.

' I should a priori have expected to have found some slight
defect of sight and corresponding changes in the vascular
supply of the optic disk in such a case, and in the case of
paralysis of the cervical sympathetic from injury to the spinal
cord. The retinal arteries are supplied with sympathetic
nerves as well as the iris, but as I could find no change in
their calibre, and no alteration of colour in the optic disk, and
as there was no loss of sight and no intolerance of light, nor,
in fact, any departure from a healthy state of the retina, it
has occurred to me that the part of the cerebro-spinal axis
which supplies the vessels of the retina (indirectly by the
sympathetic) may be different to that which supplies the iris.
If this were so, I should endeavour to ascertain if the same
holds good as regards the brain, i. e. if it and the retina are
supplied by a different region of the cerebro-spinal axis from
that which supplies the external parts of the head, iris, skin,
outer ear, &c. The meningeal arteries are chiefly branches of
the same great arterial trunks that supply the outside of the
head, so that possibly they may be under the control of the
same part of the sympathetic system as the iris, outer ear, &c.;
whilst the retina and auditory expansion, although outside
the cranium, receive branches from the arterial trunks which
supply the parts inside, and may be under the government
of the part of the sympathetic system which supplies the
brain/

Such is Dr. Jackson's experience. It is to be desired that
some skilful anatomist will really look into the question of
the effects of the sympathetic fibres and centres, whether in
the neck or in the medulla, upon the cerebral circulation.

204 THE OPHTHALMOSCOPE [CHA.

Bonders and Callenfels certainly state that irritation of the
sympathetic and its cervical ganglion in the rabbit caused
manifest narrowing of the vessels of the pia mater, followed
by paralytic distension. Such distension also followed ex-
cision of the cervical ganglion. No note was made in these
experiments of the state of the vessels of the retina, and my
own attempts to investigate the matter have been defeated by
my want of skill as an operator 5 .

Let us turn now from mere vascular changes in the fundus
to consider atrophy of the nerve.

Atrophy of the optic nerve, with or without chronic neu-
ritis, is very different in its onset and in its course from the
injected fundus ; it shows a very different process, and it
accompanies very different kinds of spinal disease ; the pre-
sumption therefore is, that one explanation will not serve for
the two sets of phenomena. Moreover, the atrophy, some-
times with chronic neuritis, is commonly met with in locomotor
ataxy, and in degenerative conditions of the cord like unto it;
but the part of the cord affected in these cases is often away
from the connections of the cervical sympathetic; and we
know, in addition, that while in locomotor ataxy the dege-
neration destroys the posterior roots, yet it invariably leaves
their ganglia whole. Nor are the threads and centres of the
sympathetic itself found, as a matter of experience, to be
diseased ; if we may rely upon the observations of Friedreich
and Carre. Duchenne, I have since read (in the Gaz. Hebd.
1 864) , found atrophy of the fibres and sclerosis of the ganglia
of the sympathicus in two well-marked cases of locomotor

5 Drs. Riegel and Jolly have lately repeated these inquiries in Von
Ruklinghausen's laboratory. They state in the February number of ' Virchow's
Archiv' that the experiments of Callenfels were insufficient, and they refer
also to others by Schultz and by Nothnagel. Schultz says (Zur Lehre v. d.
Blutbewegung im innern d. Schadels, ' St. Petersb. Med. Zeitsch.' xi. 1866,
s. 122) that on cutting or irritating the cervical sympathetic in rabbits no
change followed in the vessels of the pia mater. Nothnagel ( Virch. Arch.'
xl. s. 203) agreed with this as a rule, but thought that perhaps the vaso-motor
nerves of the pia mater might pass by the sympathetic in a few abnormal
cases?. R. and J. have, however, made a ' large series ' of careful experiments
in which they have failed to discover the slightest change in the vessels of
the pia mater on cutting or irritating the cervical sympathetic.

vi.] IN DISEASES OF THE SPINE. 205

ataxy. But what do we find when we turn to the symptoms
in these two cases? That there was not only myosis, but
vascularity, oedema, and overheat of the face and ear likewise.
These objections, not only taken together, but also taken
singly, are at least considerable, and, in my opinion, are fatal
to a belief in the sympathetic nerve as the cause of those
secondary disorders of the eye which we are discussing.

It is less easy to undertake to say what are the causes of
disorder of the optic nerve and retina in spinal affections;
I shall try, however, to find out in what direction the facts
themselves seem to lie.

It is clear, first of all, that we have to do with two distinct
kinds of consecutive disorder, and it is probable that they arise
from distinct causes. Again, these changes are not peculiar
to cases of spinal disease, but they are seen in encephalic dis-
orders also ; and, in default of evidence to the contrary, we
must assume that their causation is identical or similar in
the two. Now, this kind of hyperaemia with serous exudation,
when occurring in encephalic disorders, is, so far as my
experience goes, very commonly associated with meningitis
or extended meningeal congestion of the base ; while atrophy
or chronic neuritis is either not associated with meningitis,
or, if associated with it, is clearly -due to other causes in
particular, to disease of the encephalic vessels, to degeneration
of the optic fibres or centres, to disseminate sclerosis, or to
severance of the continuity of the encephalic optic fibres by
pressure, local neuritis, and the like. Hence my former sup-
position, that the two kinds of change have different causes,
is supported by my experience of their causation when de-
pendent on encephalic conditions 6 . Again, as I have said,
this hypersemic state seems to be less a destruction of the
nerve than a protracted interference with its vascularity, and
this state occurs rather with injuries of the spine than with
chronic degenerations of the cord. In these latter cases,
when any changes occur, they appear not to be of the nature
of a transient interference, but of an essential destruction.

6 Another important mark of difference is, that the injected fundus is often
unaccompanied by contracted pupils.

206 THE OPHTHALMOSCOPE [CHAP.

These facts seem to support the foregoing : injuries to the
spine are very commonly followed by meningeal congestion or
meningitis of a subacute character, while slow degenerations
of the cord itself are either unattended by meningitis, or the
miningitis is a mere local thickening not likely to spread.

In default of a series of autopsies, then, we seem to be led
towards the conjecture that hypersemia of the back of the eye,
following injury to the spine, is probably dependent upon a
greater or less extension of the meningeal and vascular irri-
tation up to the base of the brain. Now, have we any reason
to suppose that such irritation or inflammation does creep
up into the encephalon ? We have : for, setting aside the
curious head symptoms such patients often present, here
the actual demonstration of autopsy comes to aid us. It is
tolerably well known to careful pathologists that encephalic
meningitis is not an uncommon accompaniment of spinal
meningitis. I am glad to be able to enlist Mr. Wharton
Jones on my own side in this, who makes the same state-
ment himself on the authorities of Ollivier and Abercrombie.
It is scarcely needful to point out, that if this explanation of
an ascending meningitis be the correct one, it accords with
the observation, stated above, that, in general, the higher the
injury to the spine, the sooner the affection of the vessels of
the inner eye.

Finally, we have learnt, from our experience of encephalic
diseases, to attribute atrophy of the disks to severance of the
optic nerve fibres, to sclerosis in patches, or to travelling
degenerations, rather than to meningitis. Very commonly
it is due to what, for brevity's sake, we may call Wallerism,
from the well-known experiments of Waller upon the tra-
velling degenerations of nervous fibres. Now, as I have said,
atrophy of the disks is seen, not in recent injuries of the spine,
but in slow degenerations of the cord in cases, that is, where
meningitis is usually absent or inactive ; and it is seen most
frequently by far in that degeneration of the cord called
sclerosis of the posterior columns, which so often occurs in
connection with the extension or the dissemination of like
patches of the same process elsewhere, and particularly up-

vi.] IN DISEASES OF THE SPINE. 207

wards. On the other hand, it seems almost certain, from
clinical observation and from autopsy, that sclerosis, both of
the optic nerve and of other nerves of the base, such as the
third 7 , do accompany sclerosis of the posterior columns with
a constancy not accounted for by a propagation of the lesion
upwards, or by concomitant mischief of a like kind above the
cord ; moreover, these nerves are often affected so early, that
we can scarcely suppose that the degeneration has had time to
advance to the corpora quadrigemina, or other parts of vision,
even in the subtlest form. Nay, more ; sclerosis of the optic
nerves would seem to be actually commoner in locomotor
ataxy than in disseminate sclerosis, when lumps of hardened
nervous tissue are undoubtedly present both in cord and
encephalon. In this latter disease, however disseminate in-
sular or patchy sclerosis atrophy of the optic nerves is by
no means uncommon. Amaurosis, then, in chronic spinal
lesion, will probably be explained when the occurrence of
the like changes in the cerebro-spinal mass are explained,
and not till that time.

There remains much to be done before we can reason on spinal
amaurosis and the ophthalmic signs of spinal injury in any
adequate way ; and were it not that I thought some handling
of the few facts we have would lead to further inquiry, and
so far do indirect good, I should have deferred any essay
thereon for the present, beset as we are with the double diffi-
culty of indicating the general bearings of phenomena whose
connection is so obscure ; and, on the other hand, of avoiding
the temptation to handle the subject more freely than the
actual state of our knowledge can justify.

An important attempt has been made by Dr. Hughlings
Jackson to throw some further light upon the subject by
direct experiment. The results were negative, but are
nevertheless so important, that I think they ought to be
republished ; I therefore place Dr. Jackson's account of his

7 In locomotor ataxy we may find disorders of accommodation, palsy of
orbital muscles with double vision, and contraction of the pupils in addition to
atrophy of the optic nerve and narrowing of the visual field. The atrophy is
in some cases preceded by a transient period of more active irritation.

208 THE OPHTHALMOSCOPE [CHAP.

observations as an appendix to this chapter, to which,
perhaps, they have more affinity than to any other part of my
book. They may, however, be considered also in connection
with his observations on sleep, which I republish hereafter.

Dr. Jackson's communication to the ' Medical Times and
Gazette' for the 25th July, 1863, is entitled, An Experimental
Inquiry into the Effect of the Application of Ice to the Back of
the Neck on the Retinal Circulation, and proceeds as follows :

' At the Hospital for the Epileptic and Paralysed I tried
the following experiments, in order to see if I could influence
the eye, the size of the pupil, the calibre of the retinal
arteries, and coloration of the optic disk, by applying cold to
the back of the neck. It occurred to me to do so on reading
Dr. Chapman's communication in the last Number of the
" Medical Times and Gazette/' entitled, "A New Method of
Treating Disease by Controlling the Circulation of the Blood
in Different Parts of the Body/' The patient on whom I tried
it was a girl of fair general health, but who was subject to
sudden startings of the whole body, for which she had been
admitted. When ice was applied to the back of the neck and
upper part of the dorsal spine, I could detect no alteration
whatever in the size of the pupil. I confined my attention
to one. It varied readily in light and shade. (I tried this
experiment on another little girl several times with the same
result.) I then examined the fundus with the ophthalmoscope,
noting carefully the size of all the vessels, and the degree of
coloration of the optic disk. The nurse then applied the ice
to the back at the lower cervical and upper dorsal regions, but
there was no change whatever ; the vessels remained of the
same size, and the disk of the same colour. I next examined
when the ice was applied to the back of the head, and then to
the side of the neck, and I tried the same experiments on a
second patient ; in both with the same results.

' Now the pupil not being artificially dilated, it was o
course not very easy to estimate the size of the vessels and
the coloration of the disk. Yet I had it well and steadily
under view when the ice was applied and when it was taken
away. I, however, dilated one pupil with atropine, and then

vi.] IN DISEASES OF THE SPINE. 209

saw the disk as plainly almost as the child's face. Had it,
to use such expressions, blushed or paled, it would have been
readily detected. I looked both before, during, and after the
application of the ice. The large vessels did not alter in the
least, nor did a small artery, like a hair, that I watched with
great care ; and, what is of more importance, I did not detect
the least change in the colour of the optic disk. The ice was
applied to the back of the neck for exactly nineteen minutes.
I was very careful to keep the disk steadily under view the
moment the ice was suddenly applied and when it was sud-
denly taken off, and indeed I kept the disk under a steady
gaze nearly the whole of the nineteen minutes. Finding no
difference on taking away the ice after this long application,
it was re-applied almost directly ; and then, the disk being
under view, the nurse took the ice away, and immediately
substituted a flannel wrung out of very hot water. I could
find no change.

' I used the ordinary ophthalmoscope in the above exa-
minations.

' Next morning I examined the retina again, and this time
by the direct method. The disk seemed, of course, of large
size ; and I had no difficulty in keeping it under view at the
moment of suddenly " making contact/' and of suddenly
" breaking contact." I found no change in the size of the
arteries or veins, nor in the coloration of the disk.

' So far, then, I could see no change in the circulation, no
change of colour in the disk ; but I freely admit that very
likely with the greatest care I might be unable to detect some
little alteration of colour. Nor would any one, I suppose, who
adopts Dr. Chapman's views, believe that the changes would
be very marked, so as to be easily appreciated by the eye.
Still, these observations may be of some value, if confirmed,
in settling that point by experiment, viz. that there is no
perceptible alteration.

' I tried then to get information from patients in the hos-
pital who were using the ice for purposes of treatment as to
any alteration in the function of the eyes. [The ice is applied
for half-an-hour, and then hot flannels for half-an-hour, the

p

210

THE OPHTHALMOSCOPE,

patient sitting in a chair so that there could be no defect
from position.] One little girl complained that several times
a-day her sight was " queer ;" but this is a common complaint
in epileptics, and this patient's sight did not fail when the ice
was applied. Two other patients were not intelligent enough
to give me any answers at all. In a fourth, the answers were
unsatisfactory. I asked the patient what she felt, and she
described the local sensation, and spoke of a pain over the
right eye, and, in reply to several questions, said there was no
other feeling. But, on asking the leading question, " Is there
anything wrong with your sight when the ice is applied ?"
she said there was a little dimness.

* My object in making these experiments was not so much
for the sake of learning the effect of this treatment on the
circulation in the eye, as to be able to form some idea of its
effect on the cerebral circulation. Dr. Chapman, in the com-
munication referred to, writes (page 60) : " For example,
intending to direct a fuller and more equable flow of blood
to the brain, I apply ice to the back of the neck and between
the scapube." If the circulation in the brain were affected by
the application of ice to the back of the neck, it is, I think,
probable that the branches of the arteriae centralis retinae
would be affected too.'

P 2

The plate is taken from a drawing by Mr. Burgess made for Dr. Hughlings
Jackson, who kindly placed it at my disposal. The patient was a man aged
about twenty-four years, who had tough arteries, a hypertrophied heart, and
albuminuria. No dropsy. He suffered from epistaxis, and from fits of dif-
ferent sorts, supposed to depend upon haemorrhages into the pia mater. He
died from ' apoplexy.' Dr. Jackson went to Portsmouth to persuade the
friends to consent to an autopsy, but they refused.

CHAPTER VII.

ON THE RETINITIS ASSOCIATED WITH ALBUMINURIA l .

THERE are some cachexies or morbid states of the system,
such as that of Bright's disease, of syphilis, of certain poisons,
and the like, which affect the eye in very remarkable ways.

Those who are satisfied with current medical language are
content to say that these affections are due to the prevailing
dyscrasia of the blood. In this and the following chapters
I shall shortly describe these phenomena, which are most
important to the physician. We shall first consider the
amaurosis which occurs in connection with albuminuria.
Amaurosis was noticed as a symptom of Bright's disease by
Addison, Landouzy 2 , Tiirck 3 , Mackenzie, and many other
writers of the pre-ophthalmoscopic ages, but the first im-
portant descriptions of it are of more recent date. Grafe,
Liebreich, and Desmarres were among the first to give really
good descriptions of this amaurosis, with the help of the
mirror; and Virchow ('Arch. f. Path. Anat,' x. 170), Miiller
(' Arch. f. Oph.' iv. pp. 41 and 287), and Schweigger (' Arch.
Oph.' Bd. v. Abth. ii.) among the first to investigate the cor-
responding tissues with the microscope. That affections of
sight accompany albuminuria is now well known, though
they have not, perhaps, been so well described in English
books as they deserve.

1 Vide Liebreich's * Atlas,' plate ix. figs. I and 2, also the woodcut prefixed
to this chapter.

2 Vide 'Ann. d'Ocul.' t. xxii. and xxvi. 1849 and 1850.

3 Vide ' Zeitschr. der Wiener Aerzte,' 1850.

214 ON THE RETINITIS [CHAP.

It has not been laid down with sufficient clearness, for
instance, that in Bright's disease we have to deal with two
classes of eye disorders, We may see attacks of partial, or
even of absolute blindness coinciding with that state which
we call uraemic poisoning, but in which we can detect no
retinal changes with the mirror ; or we may have impairments
of sight which advance more gradually, last longer, and are
definitely dependent upon certain visible degenerations.

These two modes of blindness were not distinguished until
the mirror threw its light upon them, and they are even now,
though clearly described by Forster, and subsequently by
Grafe, but too often confounded by good clinicians.

The first form of Bright's blindness may complicate the
second form, occurring at intervals during its course. It
consists in repeated attacks of dimness, which accompany
headache, dulness, or convulsions ; it lasts one, two, three, or
more days, and then passes off as the other ursemic symptoms
disappear.

The blindness rarely amounts to a loss of perception of
light, but often of distinction of objects. It generally comes
on suddenly in a few minutes or hours, quickly reaches its
height, affects both eyes alike, or nearly so, and either comes
and goes at short but uncertain intervals, or varies irregularly
in its intensity. This form, which may be called Ursemic
Amaurosis, may exist alone ; may precede the second, or
retinitic form; or may complicate the latter. I have seen,
and repeatedly examined with the mirror, three cases at least,
in which ursemic amaurosis existed in a severe form, and in
which retinitis never appeared ; I have seen one case in which
ursemic amaurosis preceded the retinal form, and afterwards
complicated it ; and I have seen numbers of cases in which
attacks of ura3mic amaurosis came on during the progress of
Bright's retinitis, and caused more or less transient incre-
ments of blindness.

Grafe (loc. cit.} gives a most interesting case in which
uraemic amaurosis preceded retinal mischief; and he says,
that out of thirty-two cases of amblyopia with albuminuria,
he found thirty in which retinal changes were present, while

vii.] ASSOCIATED WITH ALBUMIN URIA. 215

in two there were no retinal changes, but there were extreme
uraemic symptoms.

The importance of distinguishing between these two forms
of blindness is not to be measured only by the importance of
the retinal changes themselves, but also by the light it may
throw upon the causation of albuminuric retinitis. Were
albuminuric retinitis a direct result of the uraemic poisoning,
we should scarcely expect ever to find marked uraemia causing
blindness, and not setting up a trace of retinitis 4 . On the
other hand, again, we frequently find retinitis without uraemic
symptoms, as I shall state hereafter. In fourteen cases out
of thirty of retinitis, Grafe (loc. cit.) had notes of the absence
of any history of ursemic symptoms, while in five more no
such symptoms were mentioned. Whether uraemic amaurosis
depend upon molecular or vascular changes in the retina
itself, or whether (as I think more likely) it is a proper
cerebral symptom, cannot as yet be decided. The most likely
guess is, that it is due to that anaemia of the nervous centres,
with or without serous exudation, which we frequently see in
death from uraemia.

I carefully examined the eyes, as I have said, in three cases
of extreme uraemic amaurosis, without discovering any varia-
tion, even in the vessels ; and in neither of these cases was
there the presence of convulsions to suggest any periodic
instability of the cerebral arteries.

The second kind of amblyopia which accompanies renal mis-
chief is the well-known and not uncommon albuminuric reti-
nitis. Few disorders of the eye present changes so definite and
so remarkable. The first stage of this disorder, as seen by the
mirror, is one to use Grafe's language of ' diffuse infiltra-
tion/ At the commencement, we do not see those spots of
degeneration which are so characteristic of later stages, but
we see a more or less rapid increase of vascularity. The retina

* Some good cases of mere ursemic amaurosis are published by Ebert and
Heusch (' Berl. Med. Gesellsch.' 1868). In a case recorded by Selberg in an
inaugural dissertation at Berlin, the amaurosis became complete (' vollstandige
gewesen sind'), lasted thus two days, and then passed off. The retinas were
perfectly normal ; there were not even apoplexies, full vessels, or oedema.
Grafe examined the eyes.

216 ON THE RETINITIS [CHAP.

for a space of from 3'" to 5'" around the disk becomes slightly
swollen, and of a grey or purplish red ; many fine vesicles
burst into view, and the retinal veins dilate unequally, and
grow tortuous ; while the arteries tend rather to shrink.
The disk is invaded also ; it becomes dark red, and suffused ;
its edges grow dim, and soon a grey, filmy exudation of
serum breaks out upon it and upon the surrounding retina,
casting a veil over them 5 . The mischiefs may not extend
beyond this point, and I believe, from my own observations,
that in many cases of recent albuminuria, such as the scar-
latinal, complete resolution of this state takes place, and
recovery follows. Mr. Bader expresses the same opinion in
his paper in ' Guy's Hospital Reports/ If resolution does
not take place, however, we have something more to look for.
This is the appearance of certain whitish spots and of extra-
vasations of blood in the retina. These spots occur in numbers,
and would seem to depend upon a coagulation of the filmy
extravasation seen upon the more central portions of the
retina, so that central vision is soon deteriorated. They
seem rarely to occur upon the peripheral portions. The
haemorrhagic spots may and often do precede the white spots
in point of time, especially if the congestive stage has been
severe; but I do not adhere to the belief encouraged by
Virchow 6 , that the white spots are simply decolourized clots.
Many of them may be so; all haemorrhagic spots, indeed, may
turn into white or whitish spots ; but I am sure that many
of the white spots have never been haemorrhages. I have
repeatedly seen fresh white spots upon such retinas after
intervals which were insufficient for the blanching of clot,
and, indeed, before any haemorrhages have occurred ; I have
also seen the white spots increasing in diameter without any
further exudations of blood.

In the admirable 'Atlas' of Liebreich we have two excellent
delineations of Bright's retina showing the white spots.

5 Liebreich says, that a true intraocular neuritis may occur at this stage,
and he gives a drawing of this in his ' Atlas,' Tab. 8, fig. 6.

6 Desmarres seems to hold this view likewise in his 'Traite des Maladies
des Yeux/ vol. iii.

vii.] ASSOCIATED WITH ALBUMINURIA. 217

These, though brilliant, are seldom quite white, but rather
of an opaque yellowish or bluish- white colour. The haemor-
rhages occur in the inner layers, whence they press outwards ;
but the spots and patches form, chiefly at least, in the granular
layers of the retina, and invade the inner from thence. Not
infrequently they may be seen to form behind a blood-vessel,
so as to thrust it forward ; while at other times they may be
seen in front of a blood-vessel, or so including it as to conceal
more or less of its length. All these latter patches, however,
in my experience, have evidently been clots. Whitish streaks
again are seen, which run along the course of the vessels, as
though formed by exudation from them, and other white
radiating streaks are often visible as the remains of blood
outpoured between the bundles of nerve fibres. In the
inverted image, with a common two-inch lens, the spots seem
to range from the size of a millet-seed or less to the size of
a hemp-seed or more. Around the yellow spot is to be seen a
group or constellation of peculiar stellate spots, differing both
in aspect and origin from those already described. These are
due to the fatty degeneration of rods of Miiller, the termina-
tions of which they are. As the large white spots and patches
increase in number and run together, they tend to surround
the disk with a zone, or, to use Liebreich's expression, with
a rampart 7 , the inner line of which is irregularly circular, or
melts into the grey interval and the disk itself, while the
outer presents salient angles which correspond to the course
of the larger vessels. This is splendidly seen with a binocular
instrument, which brings out the prominences. The large
patches have a brilliant and, to the unaccustomed observer,
almost a startling appearance. These patches surrounding
the disk may gradually invade it, its position having pro-
bably, however, been long obscured by congestion, exudation,
and proliferation.

The region of the haemorrhages is the same as that of
the spots, namely, around the disk and in the region of the
macula. They occur in numbers on the course of vessels,

7 'Arch. f. Oph.' Bd. v. Abth. ii. 1859.

218 ON THE RETINITIS [CHAP.

often behind them, or in their angles of bifurcation. They
may also, as I have said, form streaks, if they soak between
the nerve fibres ; but they present themselves more often as
irregular dirty blotches among the spots. They are seldom
large ; in the advanced stages, however, they tend to increase
in size, and a sudden and copious haemorrhage may sometimes
be seriously dangerous to the sight, or to as much of it as
remains. When we have only to do with scattered, defined
spots, and small ecchymoses, we may often hope for great
improvement ; indeed, if we keep the patient some time under
observation, we may even see actual recovery. The retinal
mischief always attacks both eyes ; but it does not seem to
advance and recede with the chief malady. In cases of cure,
the blood-vessels begin to shrink considerably in size ; those
which are decayed, shrivel and vanish; others silt up, and
others again seem to present that peculiar condensation and
thickening of the walls which is called sclerosis, and which
differs from that change in the renal arteries which Dr.
George Johnson has called ' hypertrophy,' and of which he
showed examples at the British Association Meeting at Ox-
ford in 1868. The haemorrhages whiten as they recede, com-
mencing at their periphery, and so gradually fade away.
The white spots in like manner slowly disappear, remaining
longest at their favourite part the region of the macula.
The renewed transparency of the retina allows us now to see
that the choroid has suffered, for we find yellow patches have
formed in this coat likewise, and the hexagonal cells are so
injured that the colour has run. Towards the periphery also
the vasa vorticosa have become very visible. This patch-
change in the choroid and a persistent retinal anaemia may
alone remain to tell of the mischief that has passed by.

In speaking thus of the course of Bright's retinitis, I must
be understood, of course, to speak of the eyes singly. Though
both eyes are always attacked, yet they suffer generally in
unequal degrees, or change at different rates. We may often
see the congestive stage in one eye accompanied by the dis-
seminate stage in the other, or the disseminate stage in one
accompanied by the patchy stage in the other.

vii.j ASSOCIATED WITH ALBUMINURIA. 219

The general symptoms connected with Bright's retinitis, if
any, are of course those of the kidney disease.

At the outset of the retinitis, however, patients generally
complain of headache. In a little boy, shown to me by
Mr. Teale, who was suffering from much headache, after
convalescence from scarlatina, we found diffuse infiltration
in both eyes. A gentleman once consulted me simply for
headache, in whose urine I found albumen ; and then, my
suspicions being aroused, the congestive stage of retinitis
also. As regards the special symptoms of blindness, we find
that the loss of sight sometimes creeps on almost imper-
ceptibly, or it may set in rather suddenly. The sight seldom
fails quickly, however ; and in all cases it observes some va-
rious intervals of truce, like the intermittent dyspnoea which
we also see in Bright's disease 8 .

In some cases, as in one which I recently had under my care,
sudden diminutions of visual power are due to plugging of
arterial branches : in one case (App. No. in), two were thus
occluded at an interval of about three weeks. Sudden and
large hsemorrhages also often disturb vision, which again re-
covers itself a little as the blood is reabsorbed ; finally, waves
of amblyopia may pass over the patient as intercurrent attacks
of ursemic amaurosis complicate the retinitis. If the central
parts of the retina are attacked first, which is perhaps gene-
rally the case, then useful vision is lost early and decidedly,
the visual field becomes defective, mists obscure the sight,
the outlines of objects become confused, far sight is lost, and
coloured vision and persistent blots or images may be present.
Some districts of the retina always remain unchanged, and
these portions may be seen with the mirror, or may be
detected by mapping out the field of vision. Grafe states,
however, that in one case of this kind he has seen complete
blindness ; I presume, of both eyes 9 .

8 It is said that this affection of central vision sometimes causes strabismus.
I never saw this, and am disposed to doubt it, except as a mere transient
state.

9 Jaccoud remarks, that sight is seldom quite lost in nephritic retinitis,
because the general disease does not give sufficient length of life. This is,

220 ON THE RETINITIS [CHAP.

The retinitis never precedes nephritic degeneration, as
Landouzy supposed ; yet, so silently may shrinking of the
kidney go on, that enfeeblement of sight may not infre-
quently be the first symptom which leads the sufferer to a
doctor ; and the doctor, who begins by examining the eyes for
spectacles, ends by discovering interstitial nephritis. Indeed,
the retinitis, so far from being a forerunning symptom, would
seem from my experience to be an evidence rather of decided or
advanced disease, and would lead me to give a very unfavour-
able general prognosis. As regards the special prognosis, I
think that really good vision is seldom recovered, though Grafe
speaks more cheerfully, and records three cases (loc. cit. p. 285)
of such fortunate ending. This is a point on which an oculist
has better opportunities of judging than a physician.

Such are the features of Bright's retina in its general
aspect ; let us, in the next place, look at the characters
of the tissue changes, as seen under the microscope. In this
part of the inquiry almost all that has been written has been
taken or derived from the papers of Virchow (' Verhandl. Phys.
Med. Gesell.' 2 and 3 Hft. and < V. Arch.' x. 5. 178), followed
by Wagner in same (' V. Arch.' xii. p. 2 1 8, 1 857); of Heinrich
Muller ('Arch. f. Oph.' iv. Abth. 2. 1858); of Grafe and
Schweigger (ibid. Bd. vi. Abth. 2. 1 860) ; of Liebreich (ibid.
Bd. v. Abth. 2. 1859, and 'Atlas,' 1863); and of Muller again
(in 'Wurzburg. Med. Zeitschr.' I. i. 1860). In this latter
paper Muller gives the first careful description of the
changes in the choroid ; these are also referred to by
Schweigger in the same year (1860), but in a later pub-
lication. Able chapters founded on these investigations may
be found also in the various subsequent treatises on the
eye, as in the ' Lehrbuch ' of Stellwag v. Carion, and in the
treatises of Wecker, Bader, and the English writers upon
diseases of the eye. I shall give a careful account of these
investigations, as we scarcely know how much light may
be thrown by them now and hereafter upon the intimate

I believe, an error. The process seeins after a time to reach a term, and to
cease its activity, leaving more or less of the retina destroyed. I have seen
this certainly in two cases.

vii.] ASSOCIATED WTTH ALBUMINURIA. 221

pathology of tissue change in general, and of that remarkable
change in particular through which in many persons the
whole organism passes in later life, and which shows itself
most prominently in a certain coincident degeneration of the
heart, arteries, and 'kidneys. I have before me the treatises
to which I have referred, and I have had the opportunity of
verifying myself in two cases every statement, or almost every
statement, which I shall make.

Mischief is found in three parts of the eye chiefly in the
vitreous humour, in the retina, and in the choroid. The
changes in the choroid are substantial, but those in the
vitreous are probably but an extension of those in the ad-
joining retina. However, as we picture the eye from before
backward, I shall begin with the vitreous humour.

The changes seen in it are of two kinds, the first being a
proliferation of the web of the vitreous, the second being the
development of certain linear bodies whose origin is unknown.
The proliferation is seen in an increase of the cells of the
vitreous, the humour, when hardened, seeming turbid on the
outer surface, which is near the retina ; some of these cells
have processes, but others are round, and by the side of some
of them may be seen a hyaline drop, which has escaped on
dehiscence of the cell ; nuclei again are to be seen, multiplying
and dividing, and the substance of the vitreous in these parts has
a granular aspect. These changes are best seen in the neigh-
bourhood of the more active tracts of mischief in the retina.

The second variety of products is described by Miiller as
consisting of little rods (Stabchen) of various lengths, the
longer ones being often knotted. Schweigger describes them
as fine, slightly varicose, unbranched, somewhat curly threads,
which from the periphery inwards lessen until we see them
merely as points. These little rods are flexible, and not very
brittle ; they somewhat resemble spindle-shaped spermatozoa,
or fat crystals. That they are not fat crystals, however, is
quickly shown by their behaviour under reagents. Like the
proliferating cells, they seem to be dependent upon the retinal
troubles, for they are most numerous near the affected parts
of the retina, and diminish in number as we pass inwards.

222 ON THE RETINITIS [CHAP.

I think that the inference we must draw from examination
of the vitreous is, that the changes seen have nothing cha-
racteristic or special about them, and illustrate only the way
in which the humour resents simple irritations. The clinical
observer must bear in mind, that this turbidity of the vitreous
may often modify the appearance of the retina behind it.

The changes in the retina are as special and peculiar as
those in the vitreous humour are simple and general. The
appearances I am about to describe are seen after hardening
the retina in chromic acid solution, and then making sections
of its structure. Let us suppose that the first section of the
retina is made vertically, and passes through the disk in
the axis of the optic nerve. The first object which attracts
the attention is the papilla, which is swollen, but generally
still retains its central depression. The surrounding retina is
also thickened, but falls away to its normal dimensions as it
leaves the disk. At a little distance from the disk, however,
we come again upon an increase of thickness as we follow the
section through the crown or crescent of white patches which
surrounds it. As we leave the disk, we see fatty particles,
chiefly in the granular layers, though not wholly confined to
them ; and these increase as we approach the white patches
and the circumvallation, thrusting aside the proper elements
of the retina. These fatty granules are to be found sparingly
in the inner layers, especially about the yellow spot, and
Schweigger speaks also of very fine vessels no\v to be found
in this district. The fat granules are never to be seen in
any part of Jacob's membrane.

Besides these fat granules, we discover curious little masses
or conglomerations of fibrin, which occur in both of the gran-
ular layers and in the intergranular. Near and in the circum-
vallation these fibrin deposits are less common than the fatty :
as we approach the disk, however, the reverse is seen ; the
fatty elements now fail, and fibrin masses, fibrin threads 10 ,
and actual connective tissue, take their place. Near the disk,
the connective tissue of the nerve fibre layer is much deve-

10 It seems not unlikely that some of the threads or striations in the fibrin
deposits may be due to the action of the reagents used in hardening.

vii.] ASSOCIATED WITH ALBUMINURIA. 223

loped, and the swelling of the disk is due to a great increase
of the same element, with a considerable increase of fine
vessels. The proper nerve fibres are seen to be compressed
by the new growth, and are, no doubt, much injured in this
way ; though I have myself reason to think that nerve fibres
will bear a great deal of this kind of compression without
permanent impairment.

Haemorrhages, of course, are rarely absent, and are of
various ages. They occur in different places, but numerous
small ones are generally observed in the nerve -fibre layer,
thrusting from the inner to the outer coats. The vessels
themselves are sometimes fat dotted, especially those near the
disks -j or more frequently we may see them sclerosed after the
fashion I shall presently mention: finally, they may seem,
as to me they seemed for the most part, to be healthy. I
have not found any hypertrophy of the muscular layer of the
arterioles, nor is it mentioned by any one of the numerous
observers which I have quoted. The exact mechanism of the
haemorrhages is therefore not quite clear to me, for fresh
haemorrhages may be seen as streaks in the nerve layer, or
as clots in the intergranular layer, without any evident con-
nection either with a fatty or a sclerosed vessel, but never-
theless large enough to crush the outer, or rod and cone
layers. All this may be seen with great ease, for in this
affection we find, as Miiller observes, that the elements show
a remarkable 'Isolirbarkeit,' or separability (if I may coin such a
word), which facilitates the distinction of parts, and suggests
to us that there must be some degree of sclerosis throughout.
Even Miiller's rods may be picked out almost entire, and their
degeneration around the macula lutea readily verified. This
degeneration affects all their divisions, the rods being some-
times obviously fatty up to their termination in the limitary
membrane.

The change called sclerosis, to which I have referred, is
found in albuminuric retinitis in a well-marked and very
curious degree. It affects both the blood-vessels and the nerve
fibres, the latter being changed in a way that sorely puzzled
the earlier observers. The change in the blood-vessels, which

224 ON THE RETINITIS, [CHAP.

we shall see also in the chorio-capillaris, consists in a thick-
ening of their walls with a compact, strongly refracting
matter, which narrows their lumen. It is found chiefly in
the smaller branches and the capillaries, the larger vessels
showing rather an increase of the adventitia. The nerve
fibres thus affected break up, and form nests of bodies, which
resemble ganglion cells, or spindle and caudate connective
tissue cells, except in this, that they present no nucleus.
Sometimes a certain marking occurs in them, which might
lead an unwary observer to suppose a nucleus ; but neither
this, which I am disposed to attribute to the chromic acid,
nor the bodies themselves, display the carmine reaction proper
either to ganglion cells or to connective tissue corpuscles.
Moreover, Miiller gives the following convincing reasons in
favour of their origin from nerve fibres. They take their rise
always in the fibre layer, never in the ganglion layer,
although they may by their size invade the latter. In some
places, again, undoubted nerve fibres are seen passing between
or about them ; and, finally, every transition may be detected
between these bodies and the nerve fibres. A fibre becomes
irregularly thickened, or varicose ; the varicosity is then
affected with the peculiar sclerotic change which gives it
an opalescent brightness, and the thickened and condensed
portion is finally separated, so as to form an independent
corpuscle, or rather so as to imitate one. These bodies
accumulate in nests, which bulge out the layer which covers
them ; and among them may be seen likewise some fatty
granules which may arise from degenerated connective tissue,
or more probably from broken -up nerve ( Schweigger).
Nerve fibres affected in the way described are often called
hypertrophied, which is a foolish and misleading term. I
must warn the reader not to mistake for these sclerosed fibres
the fibres which are simply enlarged from oedema, and which
are to be found in almost all cases of swollen papilla, whether
this be due to kidney disease, to cerebral tumour, or any
cause whatever. The distinction, when once seen, is easy.
The fibres, which are simply swollen, lie almost exclusively
about the disk ; they do not break off into short lengths, but

VIL] ASSOCIATED WITH ALBUMINURIA. 225

are more uniformly enlarged; they do not collect in nests; and,
finally, they have not that highly refracting quality which
distinguishes the sclerosed portions.

Such in sum are the appearances which have been found in
the retinitis of albuminuria ; and it is not difficult to account
for blindness, when we find from the very first an opacity of
the vitreous, a fatty degeneration of the granular layers to a
degree which cuts off light from Jacob's membrane and the
choroid, and an increase of vascular and connective tissue
about the disk and in the optic nerve which must always
compress its fibres, and which often, as Liebreich well shows
(vide ' Atlas,' Tab. 8, fig. 6) , amounts to an acute neuritis.

Before passing on to describe the changes found in the
choroid, it is important for us to know the degrees of con-
stancy which the retinal changes observe. My own observations
are too limited to give much help in this part of the inquiry,
but the more extensive researches of Lichtenstein n , Virchow,
Muller, Schweigger, and others, seem to prove that sclerosis
may occur without the fatty degeneration (Lichtenstein); that
fatty degeneration may be far advanced with but little scle-
rosis, and with no papillary oedema and swelling of nerve
fibres (Virchow) ; finally, that the relations in degree between
fatty degeneration and hypertrophy of connective tissue are
very variable, even in the same eye. My own limited obser-
vations lead me to think that the fatty degeneration and the
increase of connective tissue are of the same nature ; for in
some districts, and apparently in the less vascular districts,
there is a rapid proliferation of instable cells and nuclei, while
in the neighbourhood of the vascular papilla the new elements
are more stable, and weave themselves into a tissue. The
sclerosis seems to be a distinct event, always distinct as a
process, and often distinct in its time of appearance. It seems
at first sight to be misnamed, and to be something different
from that which occurs in patches in the cerebrospinal mass ;
certainly, however, it seems in the vessels to have a com-
munity of origin with thickening of the adventitia, and it
affects the nerve fibres in that form of encephalitis which

11 'De Amblyopia ex morbo Brightii.' Konigsberg, 1857.

226 0^ THE RETINITIS [CHAP.

Virchow has discovered in newly-born children, and which
essentially consists in an irritative movement of the neuroglia.
It may, therefore, be of a kindred nature with this latter pro-
cess, though at first sight so different.

The changes in the choroid in albuminuria are, as I have
said, independent of those in the retina, though of like nature
to them 12 . The so-called sclerosis is here most beautifully
seen, and bright patches of it in the chorio-capillaris are
visible. Virchow described them first 13 , and Miiller and
Schweigger admirably followed up his researches. In the
choroidal stroma we do not find much mischief. Here and
there is a sclerosed vessel ; in other places, the pigment struc-
ture contiguous to a diseased patch in the chorio-capillaris is
atrophied or spoilt, and the pigment cells are all, perhaps, a little
too adherent. In addition to this, there is generally some evi-
dence of irritation in the swelling and opacity of connective
tissue cells. Schweigger states, moreover, that there may be
a discoloration of the stroma at points where no sclerosis is
found either in it or in the vascular layer. Haemorrhages
are less commonly found in either layer than in the retina.
On stripping off the epithelium, the patches of sclerosis in
the chorio-capillaris are at once evident by their peculiar
brilliancy. The sclerosed vessels have their walls thickened
like those in the retina by a homogeneous strongly-refracting
substance, which contracts the lumen, and also makes the
outer contour unequal and bulbous. In consequence of the
narrowing of the lumen, cavities are formed in places from
which the blood corpuscles have often escaped by one or more
of the numerous communications. Sometimes, however, an
ampulla occurs, which contains a clump of blood-cells. These
will be found to be varicosities in the course of arterial trunks.
The sclerosis seems to arise in districts, and to frequent the
chorio-capillaris chiefly ; scattered traces of it may sometimes
be found in the veins also, and a few branches of the posterior

12 Galezowski, in a short essay on the retina in albuminuria, in the 'Union
Me'dicale,' May 27, 1865, says, I suppose by some oversight, 'La choroide
dans toutes les formes de la retinite albuminurique, reste intacte.'

13 Virchow, ' Verhandl. phys.-med. Gesellschaft Wurzburg,' x. p. 36.

vii.] ASSOCIATED WITH ALBUMIN URIA. 227

ciliary arteries may not escape. In addition to the closing of
the arterioles by means of sclerotic narrowing and varicosity,
we find them closed also by the coagulation of .their con-
tents. In this way long plugs are formed, which can be
teased or pressed out. A few of them contain some blood-
corpuscles, and others may contain granules and small cellular
or pseudo-cellular bodies, which may be changed leucocytes,
or have had origin in the epithelium ; many others, however,
are quite transparent and homogeneous.

The epithelium of the ciliary arteries was found by Miiller
to be much proliferated; in the choroid it is generally
loosened or lost, and with it numerous young cells suggestive
of proliferation may be seen ; there are also spindle - cells
full of fat drops, which swell and burst. Free granules may
always be seen in abundance. A very interesting kind of
peripheral embolism may be followed distinctly in the vessels
of this region, the minuter contents of the arterioles being
driven into the capillaries. In the chorio-capillaris, indeed,
this plugging leads to no great consequences, as the commu-
nications are so numerous more numerous than the plugs.
Changes of these kinds, including sclerosis, may be seen also
in the fine vessels of the stroma, but to a far less degree than
in the chorio-capillaris. As the intimate connection of ence-
phalic apoplexy with kidney mischief makes all changes of the
blood-vessels of the retina so interesting, it is curious to see
that partly in the affected vessels and partly in their neigh-
bourhood are to be seen many irregular yellowish red or
brownish masses, which chiefly consist of blood -colouring
matters, the affected parts being ochrey and opaque in
appearance.

Some of these are evidently due to mere stagnation and
change, but in other places they clearly are the result of
extravasation, though neither degeneration nor embolism of
the vessels may be discoverable. We are thus obliged to
suppose that the exudation is due to some change in the
blood rather than in its continents.

Let us now try to sum up what is to be seen in the eye of
Bright's disease.

Q 2

228 ON THE RETINITIS [CHAP.

First, we discover a remarkable vascularity of the disk, the
old vessels being distended, and a multitude of new ones
developed. Besides this, and in intimate genetic relation with
it, we find a considerable increase of connective elements in
the same parts, namely, in the disk, and in that district of the
nerve-fibre layer which lies more immediately around it.

These changes, together with the coincident infiltration of
serous and coagulable fluids, cause the loss of transparency,
and conceal the vessels and those edges of the choroid and
sclerotic which we call the margin of the disk. As these
changes advance, we see the hypertrophy of the connective
tissue extending itself up to the lamina cribrosa, sometimes even
into the depth of the optic nerve, and making itself manifest
likewise in overgrowth of the adventitia of the vessels. This
latter interference with the vessels causes emptiness of the
arteries, with consequent venous fulness, and causes, moreover,
those haemorrhages which occur first, no doubt, in vessels
which are fatty or sclerosed, but also in those which appear
to be healthy. As we leave the belt around the disk, we find
a proliferation of the granular layers of a much more unstable
kind, the instability being due, perhaps, to the diminution of
blood supply. The products therefore turn quickly into fat,
and form a crown, a crescent, or a constellation of opaque,
white prominences, surrounding the disk at a certain distance.
As time goes on, and the vessels are destroyed, those elements
which were formed between the circumvallation and the disk
may themselves undergo degenerative change, and the white
matter thus gradually invade and include the disk itself.

In the degeneration of the rods of Miiller in the less
vascular region of the macula lutea, we have a peculiar and
very interesting example of this kind of instability of con-
nective elements, and of their transformation into fat. Finally,
we notice the sclerosis of the nerve-fibres and of the vessels,
the latter being distinctly and independently visible in the
choroid likewise. How far the sclerosis may be akin to the
fatty change, I cannot say ; but my own observations have
convinced me that the proper hypertrophy and the fatty
degeneration of the connective tissue are one process, and

VIL] ASSOCIATED WITH ALBUMIN URI A. 229

their difference is noi in essentia, but in adjecto. Herein
I must venture to differ from Schweigger and Miiller, who
conceive, because the two processes take rise in distinct
places, and observe each their own district, that they must
therefore be distinct in the kind of their genesis.

If I am right, their separation into particular districts
is to be explained by the anatomical conditions of the several
parts.

I now approach the hard question which must follow :
What relation do these changes bear to other changes in the
organism, the kidneys of which are diseased ; and can we
include them in any common system of causation with those
other changes? The more I have read upon this matter, and
the more I have watched these cases, the more difficult the
answer to this question seems to be. I cannot pretend to be
able to throw any light upon it myself; nothing is revealed
to me which has not been revealed to others, and my only
excuse for writing this essay at all is, that I may describe the
facts conveniently, and set forth the problem more clearly.
I am disappointed to find that I can make no such general
co-ordination of the phenomena as to give this essay a per-
manent value.

In the first place, let us ascertain what are those other
changes to which the organisms in question submit. As
regards the retinal changes themselves, there is no doubt that
they are of a very constant character ; they occur, moreover,
so frequently, they form so intimate a part of the develop-
ment of kidney disease, and again, they belong so exclusively
to it 14 , that we cannot hesitate to endow them collectively
with the name of a symptom. They cannot be called merely
a complication, still less can they be called an accidental
coincidence. Some variations, perhaps, may be seen in the
retinal disorder; Pagenstecher and Samisch believe that there
is a form of retinitis gravidarum between retinitis albumi-

14 So it is, at least if we take them in their assembly. But if we look at
each component change singly, haemorrhages, granular cells, sclerosis, &c.,
we can parallel them with identical processes in other modes of retinitis. Here
again we are defeated in seeking a something characteristic.

230 ON THE RETINITIS [CHAP.

nurica and retinitis apoplectica, but I do not think the differ-
ence can be more than one of degree 15 .

Again, I have myself observed two or three cases in which
there has been rather a neuro-retinitis than a patchy retinitis
in Bright's disease, and Liebreich's plate referred to ('Atlas/
Tab. 8, fig. 6, ed. 1870) would seem to be an example of this.
I have attributed this, however, to a supposed oedema or
chronic inflammation of the meninges, like that which in the
same patients attacks the pericardium or pleura.

Are the kidney changes, on the other hand, as constant as
the retinal ? Scarcely so. I have been sadly disappointed
in the autopsies needed to settle this matter in three crucial
examples, which have been lost by the carelessness of others.
In one case, quoted by Dr. Dickenson in his excellent work,
I did indeed secure the kidneys from a man who died with
well-marked albuminuric retinitis, as witnessed by Mr. Teale,
Mr. Oglesby, and my old pupil Mr. Aldridge, and who had
well-marked symptoms of epithelial nephritis. The kidneys
were large, smooth, and fawn-coloured; but the one which
was put aside for minute examination was neglected and
lost 16 .

Another of the two cases was a young man under the care
of my colleague, Dr. Chadwick. He was not more than 25
years of age 17 , was a precocious beer-drinker, and worked in
the wet. He had the history of epithelial nephritis ; scanty
smoky urine rich in albumen, back pains, early acute
anasarca, waxy complexion, &c. ; he had also well-marked

15 ' Klin. Beobacht. a. d. Augenheilanstalt zu Wiesbaden,' Hft. i. 1861, p. 52.

16 Vide <Med. Times and Gazette/ May 11, 1867.

17 But I must caution the reader against the supposition that youth alone
forbids us to diagnose granular kidney. Many young women have such kidneys
as a consequence of child-bearing, and so have other young people. A very
interesting case is related by Schmidt and Wagner ('A. f. 0.' xv. 253), in which
a 'madchen,' aged 15, had double neuro-retinitis, with granular kidneys and
hypertrophy of the heart. I have never seen such a case as this, however. The
neuro-retinitis was like that described by Liebreich, and after death the peri-
papillary thickening was found to be due to increase of the " outer " layers
of the retina. On the other hand, they record a case of encephalic tumour
without albuminuria, in which the neuro-retinitis was very like that of
albuminuria.

VIL] ASSOCIATED WITH ALBUMINURIA. 231

retinitis. He had many attacks of convulsion, and ultimately
died at home, and was buried before my sentinel managed to
inform me of his decease.

The third case was like unto it in every respect. The
young man was under my care in the Infirmary for some
weeks with every symptom of tubal nephritis, and died, after
several rounds of convulsions. He had retinitis. He died
deeply comatose, and, unfortunately, on a day when I did
not enter the hospital ; by a strange caprice of fate, the autopsy
was forgotten until too late, and I learnt his death by seeing
his coffin removed by his relations.

Such cases are rarely to be met with, for, whatever be the
essential nature of the kidney mischief which accompanies
retinitis, this much at least is certain, that it must be of long
duration. Let me now turn from my own experience to that
of others, in order to learn whether in cases of retinitis other
than the granular form of kidney disease has been noticed.
The nephritis, caused by pregnancy or retro-peritoneal swell-
ings, and that consequent upon heart disease, are presumably
' granular' in all cases; but setting these aside, we undoubtedly
find many cases recorded in which the kidney mischief is of a
different kind.

Traube and Beckmann have shown that retinitis has
occurred in connection with amyloid kidney ; in the case
published by Traube, in a lecture which I have before me 18 ,
the disease was very chronic, and the kidney shrunken. The
change was undoubtedly amyloid, and followed disease of bone
with suppuration. The general symptoms, however, were
very like those of granular kidney; the left ventricle of the
heart was hypertrophied and dilated, and there was high ten-
sion of the aortic system. To this point I shall again refer.

Another important case is recorded by Dr. Russell, of
Birmingham 19 . In this case, retinitis coexisted with symp-
toms of epithelial nephritis, and an autopsy was obtained.

In answer to my minuter inquiries about the kidneys, Dr.

18 'Deutsche Klinik,' No. 7, Feb. 12, 1859. I have been unable to find any
accurate reference to Beckmann's cases.

19 'British Medical Journal,' Jan. 15, 1870.

232 ON THE RETINITIS [CHAP.

Russell wrote to me on January 22nd, 1870, as follows:-
* I was unfortunately prevented from being 1 present at the
post-mortem in the case you write about, but I received the
following particulars : ft Kidneys somewhat larger and heavier
than natural; capsule peels off easily; surface smooth, pale,
fawn-coloured. Heart, left ventricle thick, pale, fawn-coloured;
cavities of both ventricles dilated." I am sorry to say that
they neglected to weigh any of the organs.'

In default of microscopic examination, this case is still very
important evidence that retinitis does not belong to interstitial
nephritis alone ; it will be noticed, however, that in this case
also the heart was * thick. 5 Another case of importance was
mentioned to me by Dr. Hughlings Jackson some time ago.
A woman under his care had retinitis albuminurica, which
was carefully noted both. by himself and Dr. Pagenstecher.
She died shortly afterwards, when 'typical large white
kidneys ' were found. The state of the heart was not
noted. In searching through medical literature, one finds
numerous examples of retinitis with kidney disease, in which
autopsies were made; these for the most part, however,
are published by ophthalmic writers, and the description of
the kidneys is quite useless. In Dr. Bousseau's treatise on
secondary or symptomatic retinitis 20 , there are many inter-
esting cases, and some which seem to present symptoms of
the larger kidneys ; but the descriptions of these organs and
of the heart after . death are quite worthless. Dr. George
Johnson, with whom I have more than once discussed this
matter, gives me his strong opinion that retinitis may ac-
company diseased kidneys* other than the granular. He, like
myself, has failed in securing autopsies. One of his cases,
which was examined by Mr. Wells, I give in the Appendix
(No. 109) ; the other, he tells me in a letter, was a shoemaker,
aged 25, a private patient : ' He had general dropsy, and a
large amount of albumen ; oily cells and casts were very nu-
merous/ The history of the case was clearly that of a large
white kidney. He died from congestion of the lungs. No
post-mortem could be obtained. As he complained of loss of
20 ' Des reunites secondaires ou symptomatiques.' Paris, 1868.

VIL] ASSOCIATED WITH ALBUMINURIA. 233

vision I sent him to Mr. Wells, who reported, * the remains of
albuminuric retinitis 21 .' Another fact, tending to associate
retinitis with epithelial nephritis, is its frequent occurrence
after scarlet fever : cases of this consequence are to be found
abundantly in the ophthalmic journals and elsewhere 22 . I
have met with two cases in which kidney disease with retinitis
followed scarlet fever, but I have no detailed notes of them,
as they were seen by me but once in each instance. These
considerations lead me to believe that albuminuric retinitis
is not essentially connected with the granular kidney; but
I do think that, as in Traube's case and many others, the
albuminuria must be of prolonged duration in order to give
rise to it. The matter now stands thus ; that a definite and
peculiar kind of retinitis is associated with chronic disease
of the kidneys, and chiefly with that most chronic form, the
granular.

It would be, no doubt, of great importance to pathology,
could we fill up the necessarily intermediate events. Traube
and Schweigger, who are followed by many after writers,
attribute the retinal mischief directly to the hypertrophied
heart which so commonly accompanies granular kidney. I
may go so far as to say, that the occurrence of retinitis,
during other kinds of chronic nephritis, does not necessarily
forbid the introduction of enlargement of the heart as the
middle factor; for I hold that this hypertrophy of the left
ventricle may occur likewise in these other chronic kidney
diseases. I have already drawn attention to its presence in
Traube's and Russell's cases, and Dr. Grainger Stewart found
it in 39 per cent, of his cases of tubar nephritis. On further
analysis, he found it in 12.5 per cent, of the first stage ; in
38.5 per cent, of those in the second stage ; and in 100 per
cent, of the third stage. I have found it myself also very
frequently in chronic nephritis of amyloid and epithelial

21 Extract from private letter, dated July 29, 1869.

22 A case is indeed recorded of amaurosis with scarlatinal dropsy, which was
cured, together with the kidney disease, by the usual means. (Topinard, ' Gaz.
des Hopitaux,' 1861, quoted by Bousseau, loc. cit. p. 49.) No ophthalmoscopic
examination is recorded, and the case was probably one of the uraemic amau-
rosis I have distinguished from retinitis.

234 ON THE RETINITIS [CHAP.

nature, in many cases, moreover, in which there was no reti-
nitis 23 . On the other hand, I have myself seen three cases
of albuminuric nephritis, at least, in which there was no
enlargement of the heart whatever, nor any undue tension of
the arterial system, as in one of the cases I demonstrated by
the sphygmograph. Homer has likewise described cases
without hypertrophy of the heart.

When I turn, moreover, to the pithy and accurate reports of
Pagenstecher 24 , 1 find his testimony strongly in the same direc-
tion. He enumerates thirteen cases of albuminuric nephritis,
and remarks : ' In all the thirteen cases, we could diagnose heart
affections in two only.' This proportion is probably much
below the average, but it certainly shows that hypertrophy
of the left ventricle is no necessary middle term between the
eye disease and the kidney disease. I think haemorrhages,
perhaps, may be commoner, when hypertrophy of the left
ventricle is present ; but I am not at all sure even of this,
and haemorrhages are indeed common in all kinds of retinitis.
It is scarcely necessary to add that the retinitis has never
been seen to accompany a hypertrophied heart in cases other
than renal. It would seem, then, that this hypertrophy and
the retinitis are concomitant effects of some other causes, and
are not themselves, as Traube supposes, related directly 25 .

But, we may ask farther, is there a necessary relation
between the retinitis and the nephritis at all ? Are they
necessarily connected as effect and cause, or are they but
common results of some other necessary precedents? That
the two are related directly seems almost certain. Landouzy

23 Hypertrophy of the heart seems to occur sometimes, at least, as a simple
result of contraction of the kidney by any means. Dr. Conway Evans found
it in a case in which contraction of the kidney was caused by plugging of the
renal artery. (Vide ' Path. Trans.' xvii. p. 173.) It is difficult to say why this
should be ; if mere local resistance to blood-passage were the cause, we ought
to see the hypertrophy under many other circumstances of the same kind in
the liver and elsewhere.

21 Loc. clt. Hft. iii. p. 80.

2 "> I have not opened the question whether the so-called hypertrophied ven-
tricle is any stronger than before. My own observations lead me to doubt this,
and to believe that the enlargement of the ventricle is rather of a degenerative
kind; but to discuss this would be to leave my proper subject.

vii.] ASSOCIATED WITH ALBUMINURIA. 235

is the only writer who has spoken of retinitis as preceding
the nephritis, and he evidently did so in ignorance of
the subtle character of the granular disease. All clinical
experience assures us that nephritis of some kind, and espe-
cially of a chronic kind, is a necessary antecedent, and we
must hold this opinion until an exception arises. Were it
otherwise, were there a single case on record of the retinitis
preceding the nephritis, as general arterial disease and a dis-
position to encroachment of the connective tissue in many
other places may undoubtedly precede it for this my case
books can prove then it might reasonably be held that the
retinitis was not directly due to the nephritis, but that both
were a common expression of one constitutional tendency, a
tendency which might coexist with other chronic forms of
nephritic degeneration. But common as arterial degeneration
is in advancing life, I have never yet heard of this condition,
apart from the granular kidney, being accompanied by the
form of retinitis called albuminuric.

Common, too, as are irritating and prolonged states of lithia-
sis in patients whose kidneys as yet are sound, I am unaware
that this state of the blood has ever been seen associated with
the retinitis and not associated with granular kidneys. Appa-
rently, lithiasis alone is insufficient to produce it, and appa-
rently the morbid irritation of the connective elements in the
waning organism does not reach the retina until it has first
invaded the kidney. Is uraemia the middle term between
these two local diseases ? This supposition involves us in
difficulties almost as great as before. If some one or more
of the constituents of urine 26 , when left behind in the blood,
can so irritate delicate tissues as to set up mischief such as
we see in the eye, we ought to find some relation between the
degree of the uraemia and the degree of the retinitis. Biassed
as I am in favour of some such hypothesis as this, yet the
only fair ground for it is the constant concurrence of kidney
mischief, and of mischief of a chronic kind, which keeps up a

26 Uraemia does not mean, as too many writers suppose, urea in the blood,
but urine in the blood ; and this etymological meaning is fortunately more
useful than the conventional one.

236 ON THE RETINITIS [CHAP.

prolonged irritation. There seems, also, to be some reason to
attribute such a quality to uraemic blood, as this certainly
precedes irritative changes in other delicate tissues, such as
the nervous and. serous tissues. Moreover, it will be seen in
the following chapter that a peculiar retinitis is found to occur
in many cases of leukaemia, a disease which is attended with
excess of urea and uric acid in the blood, and in which we find
enlargement of the liver and the spleen, which are now under-
stood to have uropoietic functions. The enlargement of the
kidneys in leukaemia is probably but a genuine hypertrophy
due to excessive demand upon their excretory function.

On the other hand, however, comes this want of any time
relations between the uraemia, or the quality of the urine
voided, and the eye disease. Cases are numerous, and have
occurred in my own practice, where the retinitis preceded all
other obtrusive symptoms, and long preceded any symptoms
of uraemia, properly so called ; while in numbers of other
patients uraemia has been threatening, and long at work,
without causing a vestige of a cloud in the eye.

The only remaining hypothesis which I can imagine is,
that the blood, impoverished by loss of albumen, tends to
exude from the vessels. This, however, would only account
for the haemorrhages ; but I think it may explain these and the
epistaxis likewise. Certainly many haemorrhages seem to take
place from vessels which are not visibly diseased, and retinal
haemorrhages, like epistaxis, being somewhat independent of
the irritative movement, do appear more abundantly in the
extremer stages of the disease, while the irritative phenomena
may predominate in earlier stages. So at least it has been in
my experience. There appears even here, however, the difficulty
common to this explanation of the haemorrhages, and of the
epistaxis, that in epithelial nephritis, the loss of albumen and
of red corpuscles is certainly as great or greater than in the
interstitial, and yet in it retinal haemorrhages and epistaxis
are more rare.

I have failed hitherto to find any common characteristics in
kidney patients whose retinas do inflame, and in those whose
retinas resist. The immediate cause of the retinitis must be

VIL] ASSOCIATED WITH ALBUMINURIA. 237

some such common characteristic or condition, but as yet it
eludes me, and I am compelled to leave the matter before the
reader in this unsatisfactory state. Still less satisfactory, be-
cause more important, is the want of proof of any community in
change between the retina and the encephalon, or the contrary.
The sclerosis of nerve fibres, so like that seen in this and other
forms of retinitis, which Virchow and Hayem have found
also in the brains of certain children who died in infancy,
and which is probably but an evidence of simple irritation,
does not occur, so far as my search is worth anything, in the
brains of those who die with granular kidney. I have found
no distinct evidence of a proliferating neuroglia, nor of any
kindred sub -inflammatory action in the nerve matter 27 . I
should say, then, that the retinal changes would reveal to us
but little of the attitude of the encephalic tissues, were it not
for a remarkable statement of Galezowski, in the number of
the ' Union Medicale ' above quoted. He pursued his researches
in a case of albuminuric retinitis from the retina upwards
into the encephalon, and he found that ' it is not in the retina
alone that the microscope reveals material disorders, for we
find them also in the chiasma and the optic tracts. In the
right quadrigeminal body we also found a few fatty globules
and a considerable development of connective tissue/

This opens up a new and most interesting inquiry whether
the retinal changes really are but the outposts of an extensive
chronic cerebritis or sclerosis of parts of the encephalon. If
so, we may look for such changes in all cases of chronic
albuminuria ; and it is much to be desired that such search
be prosecuted. As I have said, I have examined the brains
from such patients more than once, but have failed to find
anything more than the familiar senile changes in the
arteries, with the consequent and proportionate deterioration
of the ill-nourished districts of the nerve masses.

37 Diseased vessels, and simple granular degeneration as a consequence, is
all that I found in these encephala.

CHAPTER VIIL

LEUK^MIC EETIKITIS 1 .

WHILE disease of the choroid is seldom symptomatic, dis-
ease of the retina is seldom idiopathic ; and we find another
example of this postulate in the retinitis peculiar to leuksemia.
Some years ago, on examining 1 the eyes of a leuksemic patient
in the Leeds Infirmary, I found a peculiar retinitis, of which,
however, I made no notes, and which I turned to no good
account, for my experience of diseased retinas was then not
sufficient to show me the value of the observation. The only
case I have had the opportunity of examining since was in
the Manchester Infirmary, when one day in the wards with
Dr. Simpson and Dr. Roberts. The results were negative.
Of my own knowledge, then, I can give no information con-
cerning this peculiar symptom, but I shall give a summary
of the results indicated by the following writers, whose trea-
tises are before me, and to which I shall add such comments
as their observations suggest. These writers are Liebreich ' 2 ,
Becker 3 , Leber 4 , Roth 5 , Simon 6 , and Samisch?. The prin-
cipal appearances, according to Liebreich, are (i) A pale
colour of all the retinal and choroidal vessels, especially of the
retinal veins, which, notwithstanding their repletion and

Liebreich, 'Atlas,' Plate x. fig. 3.
'Deutsche Klinik,' 1861, No. 50; 'Atlas,' pp. 20, 21.
Knapp's ' Archiv.' vol. i. No. i. Becker gives two chromolithographs.
' Klinische Monatsblatter f. Augenheilkunde,' Oct. 1869.
Virchow, 'Arch.' vol. xlix. Ft. 3, Feb. 22, 1870.

Simon, ' Zur Lehre von der Leukamie,' in ' Centralblatt,' 1868, No. 53.
Samisch, ' Ketinitis Leucaemica,' in 'Zeh. klin. Monatsbl.' Oct. 1869,
No. 1 68.

LEUK&MIC RETINITIS. 239

tortuosity, have a light pink shade similar to that of the
small apoplexies. (2) Paleness of the papilla, striated cloudi-
ness of the retina in its neighbourhood, and irregular spots
near the macula lutea. (3) A number of glistening white
round spots, which in form and colour are similar to those
found in morbus Brightii, but differ from the latter in their
peripheral situation, and hence lie beyond the limits of the
drawing. Liebreich seems to have met with such appearances
more uniformly than some other observers, as we shall see
presently. His experience is, however, so large, as to com-
mand much respect, as he has described six cases. He does
not say whether these six constitute the whole of the cases
examined, or whether some farther cases gave negative
results.

Seven years after Liebreich's first publication, Professor
Becker confirmed his observations (loc. cit.\ and more recently
again (1869), a communication appears from Leber (loc. cit.},
which he thinks anatomically confirms Becker's opinion, that
the round white spots and the stride which accompany the
vessels are produced by exudation of the white corpuscles ;
but to this we shall return.

Dr. Roth's examination demonstrated likewise a lymphoid
infiltration of the walls of the vessels, which may, however,
have been due to emigration : his essay is so painstaking, and
moreover differs in so many points from previous accounts,
that I have thought it well to make long extracts from it.

It commences as follows : ' On the 27th of July, 1869, an
autopsy was made upon R. T., aged 35, who had been under
treatment for splenic leukemia. The case is recorded by Pro-
fessor Hosier, in the "Berl. Klin. Wochenschr/' 1869, p. 357.
The section made by Professor Grohe displayed an extreme
leukaemic state of the blood, a great enlargement of the
spleen, liver, and kidneys, miliary tuberculosis of the lungs
and right pleura, purulent peritonitis, and pachymeningitis
interna, with considerable venous hypersemia of the brain and
pia mater. The eyes, which Professor Grohe had the good-
ness to hand over to me, were removed with the exception of
the anterior thirds.

240 LEUKMMIC RE TI NIT IS. [CHAP.

{ Left eye, vitreous, consistent, and clear ; retina somewhat
turbid for about four mm. round the disk, otherwise transpa-
rent. The chief veins very large and tortuous, full of blood,
and dirty red ; the arteries of medium size and fulness.
About the equator very numerous hemorrhages, the largest
being the size of a pin's-head ; the inner ones rather opaque ;
the outer (on the side of the choroid) light red. There are
an assemblage of like haemorrhages behind the equator.

' The lacunae of Blessig on the ora serrata are very wide, the
size of pins' -heads, and freely anastomosing. Choroid very full
of blood, and of a violet-brown hue.

' The right eye presents the same conditions, except that the
haemorrhages in the equator are much more numerous than
in the left eye, and one vascular branch passing backwards
and inwards from the disk is bordered by two whitish lines.

' The retinal affection was observed during life by Professor
Schirmer, who kindly sent me the following : " In the middle
of June of this year I examined both eyes of R. T. with the
ophthalmoscope, after I had already examined four other
leukemic patients in Hosier's wards, without discovering any-
thing particular. This time I found in both eyes a marked
retinitis like the plate in Liebreich's Atlas, that is, there
were close upon the disks, especially above and below them,
greyish exudations, which veiled the tortuous vessels in the
respective parts ; likewise around the macula lutea were some
uniform specks grouped concentrically, and moreover there
were a few slight apoplexies near the veins. On the other
hand, I failed to see the tint of the fundus described by
Liebreich and the bluish veins. The fundus was at most a
little brighter than normal. I had no opportunity of making
a later examination of the patient." Disturbance of vision
was not then present, nor was it observed subsequently.

* The left retina was first examined by the microscope. In
the fresh state, granule cells of various size and form were
conspicuous upon the numerous little vessels at the periphery,
especially upon the capillaries. Almost all the vessels also
were enormously full, some being equably distended, others vari-
cose. White blood corpuscles were numerous, but on account of

viii.] LEUK&MIC RETINITIS. 241

their unequal distribution could not be accurately estimated.
The chief localities for the accumulation of colourless elements
were the varicosities of the capillaries. Here red corpuscles
were often quite absent ; while the white, pressed together,
in numbers of twenty or more, until their contours were
obliterated, gave, with the closely investing capillary mem-
brane, the deceptive appearance of a gigantic, many-nucleated
cell. These accumulations of white cells in leukaemia are not
unusual, and have already been described by Virchow and
Bennett in the capillaries of the brain and lungs : according to
Charlton Bastian ("Brit. Med. Journ." 1860), emboli may thus
be formed. In one case the fusion was but apparent, and the
masses could be resolved again into common white corpuscles,
when the retina had been hardened in Miiller's liquid.

' As regards the position of the haemorrhages, their already
mentioned frequency in the peripheric portions was evident in
the first instance, and secondly, their more common occur-
rence in the outer layers of the retina. Even to the naked
eye this seemed their probable position, as the haemorrhages
seen from the inner surface appeared rather more opaque than
from without. In vertical sections were found little heaps
of red corpuscles between the inner granular layer and the
external limitary membrane ; the inner layers were more
rarely the seat of the bleeding. How far fatty degeneration
of the walls of the vessels had disposed to haemorrhage, must
be left undetermined ; in every case, indeed, extravasations
were seen issuing from vessels which did not present any
structural change.

' The lacunae near -the ora serrata were considerably dilated,
the circulation being, in fact, chiefly interfered with in the
peripheral parts. Under the microscope, the smaller gaps
were seen to be confined to the inner or outer granule layer,
while the larger ones occupied almost the whole thickness of
the retina.

' The examination of the fundus within the turbid zone was
made upon preparations hardened and coloured with osmium
and carmine. As regards the larger vessels, it was to be
remarked, that they presented but few free nucleated cells;

242 LEUKMMIC RETINITIS. [CHAP.

some of them showed a thickening of the adventitia, caused
\)j a ^ 5 fold layer of pale round cells of 0.008 mm. dia-
meter, for the most part, or sometimes of 0.006 o.oi. mm.
The large vessels appeared much dilated, thrusting the
limitans interna somewhat inwards, and so separating the
outer more yielding layers from each other, that only the
outermost granules and the limitans externa with the adherent
rods passed over the vessels.

' Haemorrhages in this district were few, as before said, and
here also affected the outer layers of the retina for the most
part. Some discrete brown masses of pigment about the disk
represented some earlier effusions. The thickness of the
retina and of its individual layers, taken all together, was not
increased, and tallied pretty nearly with Heinrich Miiller's
standard measurements.

'The supposition that the opalescence of the fundus depended
upon oedema found no support. On the contrary, the outer
fibre layer in this region was finely granular throughout, and
indeed there were granules, which took a brown colour with
osmium, enclosed in Miiller's rods, which rods were here very
greatly developed, and presented wing-like appendages. In
many places the rods were distended in a spindle-shaped
fashion, and swollen to the size of 0.035 mm - m length and
o.oi mm. in thickness. Sometimes they presented also a
pale, nuclear body of 0.007 mm - i* 1 length and 0.005 mm.
in breadth. This enlargement and the granular aspect of the
rods of Miiller were the only changes in the outer fibre layer
which would account for the diffuse opacity of the fundus.'

Some defects of the rods and cones were probably due to
maceration, and the other layers of the retina, saving a few
granule cells in the inner granule layer, presented no changes,
but the optic nerve layer contained several little nests of
hypertrophied nerve fibres near the macula lutea. ' The largest
of them was situated 4 mm. to the outer side of the central
veins; it was spindle-shaped, 0.3 mm. long, 0.16 mm. thick, and
bulged ; the limitans interna was thrust somewhat forwards, so
that the nerve layer seemed almost three times as thick as
elsewhere. Here were a large number of those peculiar bullet

viii.] LEUK&MIC RETINITIS. 243

and club-shaped bodies, made known by Zenker and Virchow,
which were sometimes pale and homogeneous, sometimes very
brilliant, and often contained a nucleoid structure. Their size
varied between 0.005 0-078 in length, whilst their greatest
thickness rarely surpassed 0.03. In the largest spindle-shaped
corpuscle, which was 0.078 in length, the round nucleus
within measured 0.02 o.oi in thickness. In the prepa-
ration, which was first tinted with osmium and then with
carmine, the outer corpuscle appeared of a red brown, and the
nucleus of a clear brown, while on simple carmine staining the
nucleus took a very intense red. The smaller nests, situated
likewise in the neighbourhood of the macula lutea, consisted
only of five or six, often of still fewer sclerosed fibres. In one
place the boundary of such a fibre was irregularly infiltrated
with pale, round, and elliptic nuclei of 0.006 o.on mm. in
size, which presented a great resemblance to the nuclei here
developed in the rods of Miiller. (Kolliker, " Gewebelehre,"
5 Aufl. S. 682.)

' The optic nerve entrance w T as examined by perpendicular
sections without anything abnormal being found ; all the
vessels here were stuffed with blood; generally speaking, in
the capillaries there were many more red corpuscles than in
those of the retina. In particular, the interstitial connective
tissue and the sheath presented no trace of lymphoid growth ;
also a few sections of the nerve, made about half an inch
behind the disk, were quite normal in character.

' The principal change in the choroid consisted in the marked
hyperaemia, already mentioned, which was equally distributed
throughout the chorio-capillaris and the choroid proper up to
the vasa vorticosa. In the larger vessels were considerable
collections of white blood corpuscles, held together by delicate
fibrin threads, probably post-mortem coagulations, while in
the capillary vessels the number of red and white corpuscles
was about equal. The isolated blood corpuscles without the
vessels were, for the most part, singly nucleated, though
some contained two or three small nuclei, and measured from
0.008 0.012 mm.

' In the posterior division of the choroid were some isolated

244 LEUK^EMIC RETINITIS. [CHAP.

jelly-like bodies, which existed very numerously in the anterior
portion, and were seated upon the elastic lamina. They mea-
sured from 0.03 o.i 8 mm. in diameter, and presented the
same characters as depicted by Bonders and H. Miiller.

' The right eye was only partially examined, but changes
were found in front of the equator as in the left eye. Thus,
in the fundus there was the same opacity and hypertrophy
of Miiller's fibres, but sclerosed nerve fibres, on the contrary,
were not found. The disk presented no anomaly; and the
choroid had the same characters as in the other eye, except
that within and above the disk was found an irregular infil-
tration of colourless, round, and club-shaped cells of 0.008
0.012 mm. in size with nuclei of 0.006 mm., or sometimes
with several small nuclei. The infiltration extended through
the chorio-capillaris and the choroid proper as far as the inner
layer of the supra-choroid. In spite of the connective tissue
growth, the choroid did not seem in these places to be thick-
ened as the vessels were correspondingly narrowed. The
infiltration ceased at the choroidal opening, but its extent
outwards was not determined/

If we sum up shortly the principal results from the foregoing
description, they comprise haemorrhages seated chiefly in the
peripheral districts and in the outer layers of the retina, far-
gone fatty degeneration of the retinal vessels (especially at
the periphery), and well-marked ectasis of the marginal spaces
(Blessig) ; diffuse opacity and hypertrophy of Miiller's rods ;
thickening of the larger blood-vessels, which in some places
have the appearance, even to the naked eye, of a whitish bor-
dering ; sclerosis of nerve fibres about the macula lutea in the
left eye, and a circumscribed lymphoid proliferation (?) in the
choroid of the right eye.

A glance at the existing literature of leuksemic retinitis
(vide Leber, Zehender's Monatsbl. 1869, S. 312 et sq., be-
sides the case of Samisch, ibid. S. 305), suffices to show the
great variety of changes possible in it ; we shall only be
enabled to comprehend these in one point of view, when we
possess thoroughly complete clinical observations, in addition
to anatomical investigations. For instance, there is but one

VIIL] LEUKMMIC RETINITIS. 245

point in this case of Dr, Roth which agrees with the changes
described as characteristic by Leber, and that is the peripheral
situation of the haemorrhages ; and even here there is this
distinction between them, that the bleedings took place in
the outer layers of the retina from the vessels which originated
in the inner granule layer, whilst in his case the haemorrhages
belonged strictly to the inner layers. In a case very recently
published by Dr. Reincke again we shall see that haemor-
rhages occurred throughout the thickness of the coats.

It is worthy of remark, that in the case of Dr. Roth the
haemorrhages were not of the dull red so often described in
leukemia, but had an intense red colour, toned down only
by the covering of the inner layers of the retina ; they were
proved also under the microscope to consist of red corpuscles
closely pressed together.

The discrepancy between the ophthalmoscopic and the
anatomical investigations in the present case was very likely
due to the considerable interval (about six weeks) that inter-
vened between the two.

On turning now to other evidence, we find that Becker
(loc. cit.} gives the following description of the appearances in
one of his two cases. The patient was a man, aged 32, who
had suffered from intermittent fever, and also from syphilis
in all its stages. He had latterly splenic leukaemia and
amblyopia, especially of the left eye. The fundus of this eye
presented interesting changes : it was of an orange yellow,
the borders of the disk slightly veiled ; the veins pale rose,
and very broad ; while the arteries were thin, distinct, and
pale yellow. At the macula lutea was seen a bright yellowish
white spot of about one-fourth the size of the disk ; it was
surrounded by a red border and some small white specks.
This coincided with an almost central scotoma, which dimin-
ished as the red border of the patch grew pale. A like yellow
prominence appeared while the patient was under observation.
It took its rise from a vein at a point about three diameters
distant from the disk. The vein was very tortuous, and
bordered on both sides with dull yellow stripes. Becker
thinks that the yellow patches were nests of migrated white

246 LEUK^EMIO RETINITIS. [CHAP.

corpuscles ; it is more probable that they were actual haemor-
rhages, haemorrhages having a centre of white corpuscles and
a capsule of red corpuscles, as we have seen was demonstrated
microscopically in other cases ; as, for instance, in the follow-
ing case of Leber : Leber found the retina of the fresh eye
slightly turbid and beset, in its anterior section especially,
with numerous round, white, prominent spots, of one milli-
metre in size at most, and surrounded by a red areola. Only
a few of these were red in the centre, but near them were also
some hsemorrhagic spots also. Some vessels were bordered by
streaks. The larger whitish spots were seen in the hardened
retina to consist of aggregated red and white corpuscles,
occupying in a few places the whole thickness of the coat.
There were no perceptible changes in the vessels, but some
vessels in the disk were seen to be compressed by layers of
closely- packed lymph bodies. The lesser collections lay in
the fibre layer, and left the granule layer free. The blood
in the retinal vessels was full of white corpuscles. Choroid
unchanged, but very hyperaemic ; in one optic nerve was
a very limited fatty degeneration of nerve fibres. Leber
is strongly of opinion that the masses in the retina were
only hsemorrhagic in small part, and were chiefly to be re-
garded as minute leuksemic tumours (kleiner leucamischer
Geschwulstheerde). He bases this opinion upon their rounded
form, their prominence, the possession of a red areola, and
their frequency in the periphery. These arguments seem
to me insufficient. Leber supposes, I presume, that this red
areola was an evidence of reaction in the surrounding tissue,
but he gives us no microscopic evidence of such reaction. In
Dr. Roth's case we had evidence of retinitis, but in this of
Leber's no changes are described which can be fairly classed
as irritative. And I shall now go on to describe a case re-
corded by Samisch (loc. dt.\ which, when taken with another
published by Dr. Eeincke, an assistant of Prof. Engel-Reimers
of Hamburg, tends rather to show that these spots are merely
haemorrhages. That there is a great tendency to haemorrhage
in leukaemia is familiar to us all, and is borne out as regards
nervous tissues by the frequency of encephalic haemorrhages

VIIL] LEUKMMIC RETINITIS* 247

in these cases ; not only so, but in the eye itself there is
evidently a great tendency to haemorrhage, as in Simon's
case (loc. cit.) there was a -haemorrhage upon the sclerotic,
and in that recorded by Samisch, sudden loss of vision in the
right eye was caused by a large extravasation within it. In
the left eye of this latter case, which had also been somewhat
dim of vision, was found some turbidity of the hinder section
of the retina, and also apoplexies, and white spots upon it, which
white spots lay near the vessels. Not only the haemorrhages
but the white spots also were seen to diminish, and new ones to
form. There were in this eye moreover large apoplexies in the
equatorial district of the choroid. The following appearances
were noted in the eyes, after hardening in Miiller's liquid :

R. eye. Vitreous contained numerous products (' Derivate')
of blood corpuscles. There was an atrophied district 9 mm.
broad by 4 mm. broad at the lower part of the retina.

L. eye. The inner granule layer of the retina was much
thickened in parts where were mulberry-like masses of blood
corpuscles. The adventitia of the larger arteries was thickened,
the connective framework cedematous near the disk, and rich
in nuclei within it. The vessels of the choroid were full
of blood in both eyes, and its stroma contained heaps of
corpuscles. Here there were slight evidences of irritation.
There was also marked choroidal mischief, which Samisch
supposes to play an important part in leukaemic retinitis.
There was no choroidal mischief, however, in Leber's case,
nor in that of Dr. Reincke 8 . Dr. Eeincke, in examining the
many encephalic bleedings which he found in his case, saw
that in a large number of them blood was effused in rings
between the media and the adventitia, and between the intima
and the media. In the larger number, however, effusion had
actually taken place into the nerve substance, though even in
these a streaked disposition along the vessels might often be
traced. These streaks, he says, in many places suggested
most strongly the notion of an emigration of leucocytes ; but
this notion was quickly dispelled by following some of them
up to a point where they became continuous with unques-

8 Virchow, ' Arch.' vol. li. part 3.

248 LEUKMMIG RETINITIS. [CHAP.

tionable haemorrhages. The eyes were hardened in Miiller's
liquid, and examined, for the first time after death, as no
opportunity for ophthalmoscopic examination had occurred
during life. There were no changes in the optic nerve nor in
the choroid, save the compression of one retinal vessel in the
disk by an accumulation of corpuscles, as noted by Leber.
The retina was beset with dull points, ranging from the
minutest size up to 2 mm. They increased in number
towards the periphery. They were mostly of a round form,
and prominent, so as to give a warty appearance to the retina,
which appearance was also to be seen on the back of the coat
when it was lifted from the choroid. These were evidently
haemorrhages, thrusting aside the layers, or lying between
them ; sometimes in the fibrous layer, sometimes between the
granule layers, sometimes among the rods and cones, while
few haemorrhages occupied the whole thickness of the coat.
Often two or more of these little lumps lay closely side by
side, or above and below, being separated only by a minute
but complete barrier of tissue. One fortunate section in the
nerve layer showed the attachment of one of them to an
underlying vessel. Another peculiarity also was generally
observed, namely, that the red corpuscles were placed
peripherally, while the middle consisted only of leucocytes.

This interesting record of Dr. Reincke, then, shows us
nothing of irritation, but many of the so-called leukaemic
tumours, masses which were, however, clearly referable to
haemorrhage rather than to lymphoid development, be this by
adenoid or connective proliferation (Virchow), or be it by
migration (Cohnheim).

Again, the close approximation without continuity of
several of them, is suggestive of an accidental origin, rather
than of a propagating process. The mutual relation in place
of the two kinds of corpuscles is again quite identical with that
seen in leukaemic haemorrhages ; and, indeed, for the matter of
that, in many so-called 'softening' thrombi likewise, and it
probably depends on the earlier death of the red corpuscles.

We are led, then, by sufficient evidence, to give up the
fascinating hypothesis of the formation of adenoid tumours in

vm.] LEUKMMIG RETINITIS. 249

the retina of leukaemia, and to fall back on the belief that
leukaemic, like albuminuric retinitis, is a combination of
haemorrhagic with irritative events, but that in both diseases
we are as yet in want of further evidence as to the mode
and causation of the latter.

This much seems to be a fair deduction from the cases already
observed, speaking, that is, from the anatomical point of view
alone, that in leukaemia there are three kinds of change in the
retina which are in some measure distinct, and in some measure
found together : the first and principal change is haemorrhagic,
the second is simply irritative and connected closely with dis-
order of the circulation, and the third consists perhaps in the
peculiar and specific products of leukaemia. These latter have as
yet been found in the retina by Leber only, and in the choroid by
Engel-Reimers and Dr. Roth, for the lymphoid infiltration of
the walls of the retinal vessels, if confined to the narrow limits in
which it has occurred hitherto, can scarcely be referred to this
special class of changes, but rather forms apart of the irritative
changes, together with the hypertrophy of Mullens fibres and
the fatty degeneration of the vessels which we frequently find
together in other kinds of retinitis ; such, for instance, as the
albuminuric. To this latter class undoubtedly belong also the
sclerosed nerve fibres, which are found likewise in the albu-
minuric and other irritative affections of the retina, affections
which present, in the midst of great variety, one uniform con-
dition, namely, an excessive disorder of the circulation, whether
systemic, intracranial, or orbital. The considerable dilatation
of the marginal vacuoles seems to be a consequence of chronic
hyperaemia of the retina. The jelly-like corpuscles of the
choroid are likewise of irritative origin, and so often occur
in senility, that in Dr. Roth's case they cannot be regarded
as having any direct connection with this peculiar retinal
disease. Finally, we must remember that while leukaemic and
albuminuric retinitis agree in presenting haemorrhagic and
irritative characters, they agree also in this, that they both
occur in conditions in which uric products are found in excess.
In the former case urea and uric acid are formed in excess,
in the latter they are insufficiently excreted.

CHAPTER IX.

ON THE KETINITIS ASSOCIATED WITH SYPHILIS.

IN my own practice, I seldom or never meet with syphilitic
retinitis, numerous as are my cases of syphilitic neuro-retinitis 1 .
The retinitis belongs to an earlier period than the neuro-
retinitis, and it is not associated, as is the latter, with intra-
cranial proliferation (vide p. 106). I have, therefore, re-
quested my friend Mr. Oglesby, who has great opportunities
for observation, and who is a singularly patient and skilful
observer, to write me the following notes upon the cases which
he sees so commonly in Mr. Teale's practice and in his own.

Effusion of serum or lymph into the nervous textures of
the retina is a characteristic feature of this disease. It not
infrequently happens that during the earlier stages the
ophthalmoscopic evidence is negative, from the fact that the
effusion of serum is so slight as to escape detection even by
the most practised observer ; or, on the other hand, the depo-
sition of lymph may be so great as to cause immediate and
alarming symptoms : then the ophthalmoscopic evidence is
at once apparent.

The pathological changes which take place are very inter-
esting, more especially so when we are cognisant that such
changes are also to be found in the retinae of those labouring
under the inherited form of the disease.

Patients suffering from the early symptoms of this disease

1 Vide cases reported by me in the fourth volume of ' St. George's Hospital
Reports' for 1870.

RETINITIS ASSOCIATED WITH SYPHILIS. 251

complain of misty vision, objects appearing ill -denned in
outline ; bright light is shunned, and application to close
work is followed by severe pain in the globe of the eye,
temple, and brow.

Hyperaemia of the retina is one of the earliest symptoms
of the disease ; and as it occurs in an active form, its early
recognition is of the utmost importance, so that means may
be employed to stay, if possible, the inflammatory mischief
which usually follows. The retinal vessels are numerous and
enlarged, and the capillary tint of the disk heightened.

Effusion of serum into the nervous textures of the retina
follows closely upon active congestion. It is characterized
by the grey hazy look which it imparts, and is most readily
seen when it encircles the disk, rendering its outline indistinct.
The effusion poured out does not, as a rule, spread uniformly,
but rather selects certain sections of the retina, and in no part
is it to be found more frequently than in the neighbourhood
of the yellow spot.

In those cases in which the effusion has invaded the entire
membrane, we not uncommonly meet with turbidity of the
vitreous humour, and often of a density sufficient to baffle any
attempt at a thorough ophthalmoscopic examination. In such
cases, the mapping out of the field of vision is of essential
importance.

Should great infiltration of serum have taken place around
the edges of the disk, tortuosity of the veins will be a promi-
nent ophthalmoscopic appearance.

The effusion of lymph into the nervous textures is a symp-
tom of serious significance. If it should take place with great
rapidity, purulent infiltration of the entire membrane may
result, with very rapid destruction of vision. On the other
hand, if the deposition of lymph be gradual, and confined to
isolated portions of the retina, the prognosis may be a hopeful
one. In the latter condition, the patches, singularly enough,
are frequently found in the course of one or other of the large
retinal vessels. They somewhat resemble in appearance the
bright spots seen in nephritic retinitis, and have not infre-
quently been mistaken for them. On close examination, there

252 RETINITIS ASSOCIATED WITH SYPHILIS.

is a marked difference, for they are not so brilliant in colour,
and there is an evident peculiarity about their size and shape,
which to a practised eye is easily recognizable. In a case
of great interest, there occurred two patches of lymph, one
slightly above the disk, the other immediately below, which
had been mistaken for congenital nerve patches by more than
one observer. This case occurred in a young man suffering
from hereditary syphilis. Numerous cases of this kind are
to be found from time to time in the out-patient room of an
ophthalmic hospital ; and since the writer's attention was first
drawn to the subject, he has been able to trace the disease
through many of its phases.

Syphilitic retinitis is often present during acute attacks
of iritis, and not infrequently follows inflammation of the
choroid, or occurs simultaneously with that disease. Unlike
the retinitis of albuminuria, it is often confined to one eye.

If the field of vision be carefully mapped in a number of
cases, it will be found that peripheral contraction is a well-
marked symptom during the early stages of the disease.

Hypertrophy of the connective tissue, deposition of pigment,
and atrophy of retina, may all occur as sequences of the
disease.

With regard to treatment, mercury is the most suitable
remedy, and has a more rapid and certain influence in check-
ing the disease than any other drug. Mercurial inunction
is perhaps the least unpleasant manner of producing its
specific effect. Next in merit stands the iodide of potassium,
which, when given in large and increasing doses, often acts
beneficially.

CHAPTER X.

I

ON THE AMAUROSIS OF DIABETES.

THAT cataract commonly appears in the course of glycosuria
is well known; it would seem to depend upon the physical
reaction between the sugar in the blood and the tissue of the
lens, so that the two phenomena, glycosuria and cataract, rise
and fall together. (Seegen.) The cataract is not likely to be
overlooked by patients or by the medical adviser, and it needs
little further consideration in this place.

It is not so well known that lesions of the fundus are also
found in glycosuria, but changes, both atrophic and inflam-
matory, are described by several observers, such as Grafe l ,
Lecorche, Galezowski, Bouchut, and others. Some of these
writers describe inflammatory changes in the fundus which
bear a suspicious resemblance to albuminuric retinitis. It is
likely that some error of diagnosis has crept in here, and that
the observers, whose attention was given chiefly to the eye,
had not sufficiently investigated the general symptoms.
Actual renal disease is not infrequently associated with
glycosuria, and albumen might, perhaps, have been found in
the cases to which I refer, had not the presence of the sugar
prematurely satisfied the analyst.

In future, any appearance of retinitis ought to sharpen the
search for albumen.

Atrophy of the optic disks, on the other hand, does un-
doubtedly occur in a sufficient number of cases of glycosuria
to make the co-existence seem more than accidental. Grafe

1 ' Deutsche Klinik,' 1859, No. 10.

254 ON THE AMAUROSIS OF DIABETES. [CHAP.

(loc. cit.} was, I believe, the first to note the connection, and
many cases have since been published.

I have found it in one case out of five which I have ex-
amined. I see that Professor Seegen, of Leipzig, in his new
work 2 , includes diminution of visual power among the
symptoms of diabetes mellitus ; and if the connection be
regarded as established, it may be of great importance. It
admits of being viewed in two lights : first, in the light in
which Professor Seegen views it, namely, as a mere expres-
sion of exhaustion from innutrition ; secondly, in the more
interesting light which I am tempted to throw upon it, namely,
that the nerve atrophy is but one part of that mischief in the
central nervous system which probably lies behind the disorder
of the liver as a cause of glycosuria. Recent observation,
both experimental and clinical, points to the belief that
glycosuria is, as a disease, a disease of the nervous system.
It is clear that the fatty and other changes found in the liver
after death are inessential ; and such causes as mental strain
or distress which seem to produce many cases of diabetes,
would act rather upon the nervous centres. Heredity, again,
which is known or believed to have an important place in the
establishment of glycosuria, points rather to the nervous
system, for heredity is so commonly observed in diseases of
the nervous system ; moreover, heredity in glycosuria is by no
means always seen as such, but antecedent forms of disease,
more obviously nervous, are often seen in the parents or
relations. The last diabetic patient who came under my care
was one of four brothers ; the three who survive him are all
of peculiar nervous temperament, and one of them is actually
of unsound mind. All three are still young, and will probably
suffer more seriously from nervous disease.

Still more important evidence is obtained from the marked
tendency to obvious nervous disease in diabetics themselves.
I need not enumerate the many cases on record of the co-
existence of disease in the nervous centres with glycosuria.
Among references immediately at hand is a case of cysticercus

2 Der Diabetes Mellitus, auf Grundlage Zahlreicher Beobachtungen dar-
gestellt, von Dr. Seegen, Prof. &c., Leipzig.' Weigel, 1870.

x.] ON THE AMA UROSIS OF DIABETES. 255

in the posterior brain accompanied by glycosuria, reported by
Cyon ; a like case, published by Kosenthal in his new volume
(foot-note, loc. cit. p. 66), where diabetes mellitus and atrophy
of the optic disk (observed by Jager) were among the symp-
toms of a tumour at the base of the encephalon ; observations
on palsy of the soft palate in diabetes recorded by Dr. Sanders ;
and an essay, founded on several cases, by Dr. J. W. Ogle,
in the first volume of the ( St. George's Hospital Reports/
Dr. Dickenson has also collected and, I believe, published
several instances of the same kind. A patient of Dr. Bron-
ner, of Bradford, came to me some months ago with a long
history of glycosuria associated with chronic degenerative
disease of the cerebro-spinal centres, the precise nature of which
is uncertain, and, fortunately for the patient, is as yet out of
reach.

In Dr. E/osenthal's case, it seems probable that the optic
atrophy was a direct result of the basilar tumour, and in no
intimate association with the glycosuria; but if we find, as
I think I may say is the fact, that glycosuria is intimately
connected with central nervous lesion, and that atrophy of the
disks is often associated with glycosuria, it becomes a matter
of deep interest to us to know whether the optic atrophy may
not be regarded as an outlying part of the central mischief.

Unfortunately I have been disappointed in the autopsies
which would have enabled me to give an opinion on this point ;
but when, after the vain endeavours of two or three years, I
mentioned the matter to Lockhart Clarke, that wonderful ob-
server immediately produced some slides displaying granular
disintegrations about the calamus scriptorius, removed from a
diabetic patient, a discovery which harmonizes more exactly
with experimental results than clinical and pathological ob-
servations are wont to do.

CHAPTER XL

OXALUKIA.

As cases are published of optic change co-existing with
oxaluria, I think it well to draw attention to them. In the
' Ophthalmic Review' (vol. i. p. 213) a neuro-retinitis is de-
scribed by Mr. Mackenzie as due to oxaluria. Turbidity of
the vitreous is also described as having a like origin. The
administration of the mineral acids is said to have brought
about an improvement. Mackenzie believes that the neuritis is
due to a poisoning of the blood by way of a faulty digestion.
The matter has, indeed, two aspects : first, we may inquire
whether the accidental presence of oxalates is able of itself to
injure the retina by a physical reaction of the kind of osmosis,
or by means of such irritation as oxalic acid produces in
tissues with which it comes in contact; or we may ask,
whether the neuritis and the oxalates are both evidences of
some anterior and peculiar constitutional state ?

The first question I leave open, as I have no evidence to
lead me to a reply. As to the second, I would remind the
reader that oxaluria is no longer regarded by physicians as
significant of a particular group of changes, but is a symptom
unattached, which may present itself among many various
groups. Either, then, neuro-retinitis may be caused by the
direct action of oxalic acid, however formed, upon these
tissues, which is too important a supposition, both in itself
and in its remoter bearings, to be slightly dealt with ; or the
oxaluria was but a subordinate phenomenon in some disease,
perhaps of the nervous system, in which neuro-retinitis also
appeared as an independent event.

CHAPTER XII.

TOXIC AMAUKOSES.

SECTION I.

Amaurosis from Alcohol Poisoning.

IT is easier to ascertain the effects of alcohol upon the
nerve of sight than those of tobacco, because the other results
of alcoholic poisoning are better known, and its pathological
consequences more familiar to all. There is accordingly more
agreement among ophthalmic surgeons concerning the effects
of alcohol than concerning the effects of tobacco, the evidence
of over-use in any given person being more obscure in the
latter than in the former case. Observers agree in believing
that prolonged alcoholic intoxication exercises a distinct and
primary effect upon the optic nerve, in addition to its other
consequences.

It seems almost certain that the nerve may not only suffer
indirectly as a consequence of intracranial degenerations,
but that it presents primary and independent changes of its
own, which may or may not march pari passu with the like
changes in the cerebro-spinal axis. A study of the effects of
alcohol upon the optic nerves is therefore full of interest and
instruction, being, as they probably are, but a visible part
of those going on in other districts of nerve tissue which lie
beyond our sight. In speaking of alcohol, I use that word
alone, as it seems probable that the mischievous effects of
drinks of this kind are, for the most part, in proportion only
to the amount of alcohol they respectively contain. I may

258 TOXIC AM A UROSES. [CHAP.

mention, only to dismiss with a few words, a kind of
amblyopia, not at all uncommon in drunkards, in which
there are no obvious changes in the fundus. As in uraemia,
there is an amblyopia potatorum with ophthalmoscopic signs,
and an amblyopia without them. This latter defect is not
rare, and may be due to a congestion of the choroid, with con-
sequent pressure upon the rod layer of the retina. This can
only be guessed at from the well-known tendency of alcohol
to cause congestion of the blood-vessels of the head and face,
for I do not think that any observer would venture to say that
he could distinguish moderate and simple hypersemia of the
choroid with the mirror. It does, however, seem certain, from
much testimony, that this amblyopia is quickly relieved by
local bleeding.

The other kind of amblyopia seems to depend upon the
same congestion, with consequent tissue deterioration in the
optic nerves, which we see also in the brain of drunkards, and
which causes the opacity of the pia mater and arachnoid of
such persons. The action upon the highly vascular optic
nerve seems to me to be parallel to this action upon the
membranes. My own experience bears me out fully in saying
that congestion of the vessels of the disk and retina is very
common in patients who present themselves with symptoms
of alcohol poisoning, which class of persons appear in large
numbers in the out-patient consulting-rooms at the Infirmary.
I always examine the fundus in cases of delirium tremens, as
soon as restored tranquillity will allow me to do so, and in
the great majority of cases I find congestion and opalescence
of the disk and full retinal veins. Sight often remains un-
affected, or its dimness passes unheeded as a part of the head-
ache and mental confusion 1 . When I worked in Mr. Teale's
eye-clinic, I met with many of this kind of persons whose

1 Galezowski has published a number of observations of colour blindnesses
as seen in disease of the nervous parts of vision. I have not discussed them
anywhere, as I have not made any adequate examination into the matter, and
Leber has shown in the fifteenth volume of the ' A. f. O.' that such functional
disorders are of no use in warning us of commencing or of threatened atrophy.
When therefore the sight -fields are complete, as in alcohol poisoning, the
colour tests are of no diagnostic value.

xii.] TOXIC AMA UROSES. 259

congestion had passed on into low proliferative action with
atrophic contraction, the disk becoming- reddish grey, then
greyish blue, and finally greyish white. The fine vessels also
vanish, but the larger veins of the retina remain longer in
a state of fulness.

I much doubt the value of the recent experiments which
are said to show that alcohol, opium, and chloroform attack
the myeline, coagulating it, as it were, and breaking it up
L.to minute brilliant points.

Changes like these so soon arise in the course of the pre-
paration or decay of the parts examined, that such assertions
can scarcely expect as yet to receive much credence 2 . I
believe that the alcohol acts rather as an irritant to the
highly vascular brain and optic nerves, as it does to the liver,
and, -pace Dickenson, the kidneys and arteries, setting up
proliferation of the connective elements with contraction and
atrophy. Among the symptoms which lead one to examine
the fundus in drunkards, are loss of strength and appetite,
coated or raw tongue, vomiting, confusion of mind, loss of
memory, trembling of the lips, and disturbed sleep.

SECTION II.

Tobacco Amaurosis.

It is very difficult to discuss the well-known proposition,
that the excessive number of cases of amaurosis occurring in
the male sex are due, in great part, to the smoking of tobacco
by that sex. While, on the one hand, observers who form
this opinion are bound to state it ; yet, on the other hand,
it is so difficult to isolate the antecedents of amaurosis in
men, in order to distinguish those which are essential ; and,
again, if the efficiency of several antecedents be estimated,

2 Nor, on the other hand, can I attach much importance to the negative
results of Dr. Paul Huge, of Berlin, who examined the effects of alcohol upon
many animals. The important condition of the long-continued use of alcohol is
not present in such experiments. So far they differ from the pathological
results of myself and many others.

S 2

260 TOXIC AHA UROSES. [CHAP.

it is so difficult to say which of several true causes is the
actual cause, that those who, like myself, have not the oppor-
tunity of pursuing the facts themselves on a large scale, are
reduced to the somewhat invidious task of comparing the
qualifications of those who have such opportunities, and who
pronounce accordingly on one side or the other. After what
I have said concerning the action of alcohol, for instance, the
reader will see how hard it is to separate the two agencies,
alcohol and tobacco, in their effects upon the nervous system,
the use of the two being so commonly found in one patient.

One thing is clear, and must have a certain weight, namely,
that a very considerable number of our best observers, both
at home and abroad, and observers who have had large expe-
rience, express themselves very strongly, if not very decidedly,
upon the efficacy of the use of tobacco to cause amaurosis.

Before the ophthalmoscope was discovered, Mackenzie spoke
as follows : ' I have already had occasion repeatedly to hint
my suspicion that one of the narcotico-acrids which custom
has foolishly introduced into common use, namely, tobacco, is
a frequent cause of amaurosis. A majority of the amaurotic
patients by whom I have been consulted have been in the
habit of chewing, and still oftener of smoking, tobacco in large
quantities. It is difficult, of course, to prove that blindness
is owing to any one particular cause, when, perhaps, several
causes favourable to its production have for a length of time
been acting on the individual ; and it is especially difficult to
trace the operation of a poison daily applied to the body, for
years, in such quantities as to produce at a time only a
small amount of deleterious influence, the accumulative effect
being at last merely the insensibility of a certain set of
nervous organs. At the same time, we are familiar with the
consequences of minute portions of other poisons which are
permitted to operate for a length of time on the constitution,
such as alcohol, opium, lead, arsenic, mercury, &c. ; and we
can scarcely doubt that a poison so deleterious as tobacco
must also produce its own peculiar injurious effect V Well
and carefully expressed as is this passage, we cannot but see
3 Loc. cit. p. 888.

XIL] TOXIC AMAUROSES. 261

that Mackenzie had a strong tendency on a priori grounds to
anticipate the results which he describes; and we are disposed
to inquire how; large a percentage of patients suffering from
whatever other kind of disease are smokers ? When, again, a
person is described as a great smoker, unless we have some
definite information concerning the quantity of tobacco used,
we are obliged to remember that the standard of moderate
smoking varies according to the prejudices of the physician.
A patient was sent to me from a distance the other day as a
sufferer from the effects of excessive smoking ; but taking one
week with another, I could not make out that more than
one ounce of the weed was used in that time.

There is, moreover, this important and curious fact to be
remembered, that many substances which are intensely poi-
sonous in concentrated forms, are nevertheless innocent, if
not useful, when administered in repeated and feeble doses.
The experiments upon lower animals with the essential oil
of tobacco, which are quoted by Mackenzie in support of his
opinion, are by no means strong evidence of the likelihood
that any similar effect would be produced by ordinary smoking.
To use the words of C. S. C.,

' Cats may have had their goose
Cooked by tobacco-juice ;
Still, why deny its use,
Thoughtfully taken 1 '

I am not an habitual smoker myself, but I can scarcely
avoid the conviction that it is decidedly useful to many of my
acquaintances, and seems to be harmless even to those aban-
doned Turks and Teutons ' who smoke perennial pipes and
spit.' The increase of amaurosis, indeed, seems to be like the
increase of insanity it appears in numbers corresponding to
the capacity of the institutions prepared for its reception, so
we cannot be sure that its frequency in our ophthalmic
clinics is any consequence of the wider use of tobacco. Where
we have, if possible, to isolate any one condition, such as
tobacco smoking, we can only hope to eliminate accidents
by including very large numbers, not of amaurotics, but of

262 TOXIC AMA UROSES. [CHAP.

smokers, in our survey, and comparing them with like num-
bers of abstainers.

Mr. Carter is the only observer, so far as I know, who has
seen the necessity of handling the question widely in this
way. Mr. Carter, in his well-known work founded upon that
of Zander, compares the experience of the English with cer-
tain Eastern physicians. ' I was myself/ he says, ' for many
months resident in various parts of Asiatic Turkey, and had
opportunities of becoming acquainted with the prevalent dis-
eases of the country, among which, so far as I saw, amaurosis
could not be numbered/ Mr. Carter also received the fol-
lowing additional information. Mr. Farquhar, for many years
surgeon to the British Consulate at Alexandria, says : ' In
answer to your inquiry respecting amaurosis, I can only say,
that during the whole of my residence in Egypt, and among
the many thousand diseased eyes which I examined, it was
always a mystery to me that I saw so few cases of this
affection. The Egyptians, if it be possible, smoke even more
than the Turks/

Dr. Dickson, the physician to the British Embassy at
Constantinople, writes : * Amaurosis, taking the term in its
widest sense, is not a common complaint in Constantinople,
or in Turkey generally ; and yet smoking tobacco is so pre-
valent a vice, that it is practised by the whole population,
Mohammedans, Christians, and Jews, with hardly a single
exception. The usual amount consumed by one person, per
month, may be estimated at 2 4 Ibs. avoirdupois. In addition
to my own testimony, I may add that of Dr. Millinger,
one of the oldest and most celebrated physicians here, who
declared to me that amaurosis was a rare affection in Con-
stantinople/ Dr. Dickson adds, curiously enough, ' During
a ten years' practice at Tripoli, I found that amaurosis was a
common affection there, and yet the natives never smoke/

Dr. Hiibsch, the chief oculist in Constantinople, writes to
the same effect, and in the course of a very interesting letter
says : ' Je n'ai jamais pu attribuer Famaurose a 1'abus du
tabac ; le nombre des fumeurs est immense, le nombre des
amauroses est limiteV

xii.] TOXIC AMA UROSES. 263

If we turn, again, to the workers in tobacco manufactories,
we are unable to find that amaurosis occurs with any undue
frequency among them, although we do find distinct evidence
of certain degrees of poisoning, as shown in disorders of the
nervous system. In Leeds, tobacco is largely manufactured,
but my own inquiries have failed to discover any prevalence
of amaurosis, even among persons who have worked fifteen or
twenty years at the occupation. Mr. Oglesby, of Leeds, a
most industrious worker, with large opportunities of observa-
tion, tells me that in all his experience he has met with but
two cases which seem to bear out the belief that amaurosis may
be due to tobacco. These two cases are, however, so striking,
that I have obtained his permission to publish them in the
Appendix (Nos. 122, 123). The two cases seem to suggest that
enormous use of tobacco may, in rare cases, so deteriorate the
nervous centres, that the optic nerves suffer with other parts ;
but they do not, I think, help to prove that tobacco has any
special and isolated effect upon them in cases where the rest
of the nervous system betrays no symptoms of injury.

At the same time, it will not do to forget that the supporters
of the belief in tobacco as a cause of amaurosis are among
the greatest names in ophthalmic science. I have already
cited Mackenzie, and next to him I may place Sichel, who
speaks strongly to the same effect 4 .

Among recent English writers, Mr. Wordsworth and Mr.
Hutchinson have urged the same opinion, and Mr. Critchett
is understood to have expressed himself in like manner.

It is worthy of note, that the German observers speak very
cautiously and doubtingly concerning this effect of tobacco ;
and although our own writers have quite as much claim to be
heard as those of Germany, yet, on the other hand, it must be
remembered that the German oculists practise in the midst of
people incessantly occupied in smoking pipes of very strong
tobaccos.

Nor has Sichel found many decided supporters in France.
Follin, in his article 'Amaurosis,' in the Dictionnaire Ency-

4 ' Influence du tabac sur la vue,' in ' Annales d'Ocul.' 1865. And previously
in 'Union Me*dicale/ 1860-63.

264 TOXIC AMAUROSES. [CHAP.

clopedique, speaks with much hesitation as to the effects of
tobacco ; and of the two cases of the kind which he records,
one died of well-marked cerebral disease, which, whether itself
due to tobacco or not, was probably the direct cause of the
amaurosis ; the other is said to have recovered on laying his
habit aside : but as people do not recover in this simple way
from white atrophy, it seems more likely that the amaurosis
was but an instance of that anaemia (vide page 50), which
is a common consequence of exhausting causes of almost
any kind.

While, then, it would be neither courteous, nor in the in-
terest of our common purpose, to treat lightly such testimony
as that of Mr. Wordsworth and those who agree with him,
yet I may be permitted to indicate these three great difficulties
which are inherent in the subject. First, as I have said,
amaurosis is very common, and is common in certain districts
especially, but in districts which do not coincide with the dis-
tricts of the principal manufacture or consumption of tobacco.
Secondly, that many causes are at work, in this present busy age
especially, which may have far more to do with the causation
of amaurosis : I may refer to the use of alcohol as one of these;
as another, to the incessant over-use of the eyes in a large
number of the competitive trades in which men especially are
engaged ; and again, to those many strains upon the mind
and nerves which overtask the nervous centres, and carry the
optic nerves with them. Thirdly, that in many cases of so-
called recovery from amaurosis on omission of smoking, we
have no certain evidence that the condition was not one of
general anaemia, made especially manifest in that kind of loss
of vision which accompanies menorrhagia, lactation, and the
like. Unfortunately, mapping of the field does not help us
much here, as in amaurosis from toxic causes the diminution
of vision is often uniform all over the field. Fourthly, we
have no satisfactory evidence that the cases quoted were
well watched for any length of time. Degenerative nervous
disease, such as locomotor ataxy, general paralysis, and dis-
seminate sclerosis, are commoner in men than in women ; and
of such diseases, white atrophy of the optic nerve may be the

Fig. 2.

Fig. 3.

E. Burgess dei a*3.-ru>Lct ,A I'll, W West

"NETJRITIS FROM LEAD -'POISONING .

XIL] TOXIC AM A U ROSES. 265

first sign : see, for instance, the case of MacCarthy, No. 79 in
the Appendix. In ophthalmic clinics, the a' tention of the sur-
geon is given chiefly to the eye ; he has neither the time nor the
habitual tendency to inquire into and make himself familiar with
obscure forms of central nervous disease ; and any physician
among my readers, who has been accustomed to turn over
ophthalmic treatises and reports, will bear me out when I say,
that in cases of optic neuritis, albuminuric retinitis, and the
like, the poverty and inadequacy of the report of the medical
details is too often so great as to make the case useless as
evidence of anything. To no ophthalmic surgeons do these
strictures apply with less force than to Mr. Hutchinson and
Mr. Wordsworth ; but I cannot refrain from saying, that the
description given by Mr. Wordsworth of the onset and course
of the amaurosis of tobacco, and which he thinks is peculiar
to that amaurosis 5 , is nevertheless the exact description of
amauroses which have been watched throughout by myself in
many forms of cerebro-spinal disease, and in general paralysis
in particular.

SECTION III.

Lead Poisoning*.

The action of lead in the organism tends, as is well known,
to produce a deterioration of the nervous system, and, more-
over, to select certain parts of that system in a way which
seems to us as yet to be capricious. The eye suffers as one of
these parts, and it suffers in three ways. Firstly, the effects
of lead may be seen in the ciliary muscle, causing palsy of
accommodation : secondly, in the optic nerve, causing atrophy
thereof, which atrophy is sometimes preceded by a stage of
subacute irritation: thirdly, and indirectly, by causing gra-
nular degeneration of the kidney, with its peculiar retinitis.

The first of these effects is only indicated, as it lies beyond

5 Carter's 'Zander,' p. 132.

6 Vide plate prefixed to this chapter. These plates serve well, also, for illus-
tration of some sections of the fourth chapter.

266 TOXIG AMA UROSES. [CHAP.

the subject-matter of this work ; and the third, which is,
perhaps, the most frequent, has already been described in
Chapter VII. We have only to deal, therefore, with the
second, with atrophy of the optic nerve, preceded or not pre-
ceded by chronic or subacute neuritis. If complicated with
palsy of the ciliary muscle, the case will be readily simplified
by the use of an appropriate convex lens.

I have seen but one case of saturnine atrophy, and this
was some time ago : I publish brief notes of the case in the
Appendix, No. 120. Lead poisoning is very uncommon here,
as there are no trades in Leeds which favour it ; the house-
painters no longer grind their own colours in winter as they
used to do, so that among them lead poisoning has almost
ceased to exist. Many cases are recorded, however, in the
journals, both home and foreign ; still, I am disposed to think
that the event is one of the less common results of lead poi-
soning. Christison, for instance, makes no allusion to amau-
rosis as a result of lead poisoning. E. Meyer published in the
'Union Medicale' two cases, which were read at the Medical
Society of the Elysee on Feb. 3, 1868 : in one of his cases
there was white tendinous atrophy, with complete blindness ;
but in the second, there was well-marked neuro-retinitis. This
case is published in the Appendix, No. 117. In my own case,
that of an out-patient of the Leeds Infirmary, there were
grave symptoms of intracranial mischief -symptoms, which
pointed to softening, complicated with some haemorrhage.
In Meyer's case, also, there were serious cerebral symptoms.
In these instances, it may sometimes be difficult to say
whether the -optic atrophy is direct or indirect; whether, that
is, it succumbs, like the encephalic parts, to the direct action
of the lead, or whether its changes be merely symptomatic of
intracranial lesion of whatever causation.

Saturnine amaurosis was noticed in prae-ophthalmoscopic
ages; the earliest reference which I have in my possession
being to Duplay, in the * Archives Generates de Medicine, ii e
serie, torn. v. p. 5. Paris, 1834. I have not seen the original ;
the reference is copied from Mackenzie.

It is to Mr. Hutchinson, however, that we owe the most

xii.] TOXIC AM AU ROSES. 267

important essay on saturnine amaurosis. This essay was
published, with illustrations, by Mr. Hutchinson in the seventh
volume of the ' Royal Ophthalmic Hospital Reports.' The
number appeared while these sheets were in the printer's
hands, and I am enabled by the kindness of the author to
reproduce his illustrations in this place. Mr. Hutchinson
gives notes of five well-marked cases, four of which were
under his own care, and the fifth under Dr, Charlton, of
Newcastle. The first case, in a young woman, aged 19, had
been described in the preceding volume of the ' Reports,' and
is thence quoted by me in the Appendix, No. 119. The
second and following cases are so important, both in them-
selves and in their bearings upon the whole question of lead
poisoning, that I venture to quote them in their entirety.

CASE II. Double optic neuritis in connection with lead poison-
ing, but without other symptoms Constitutional symptoms of
neuritis ill-marked Description of the disks.

William Argent, aet. 40, has been a house - painter for
twenty years past. He is now a pale complexioned man, and
around his teeth is a very marked blue line. He asserts,
however, that he has never suffered from lead colic, nor from
any other illness which he attributed to the paint. In No-
vember, 1867, he was laid up for three weeks with ' rheumatics/
and had swelling of the backs of hands, great toes, and ancles.
Often before that he had suffered from rheumatic pains in
various parts. His sight has never been quite what it was
since this illness. Two or three months ago, however, it
failed more decidedly, and he now found that his left eye was
much worse than the right. He has for the last few years
often suffered from pain in the head, which he considered
rheumatic ; it appears to have been a frontal neuralgia. At
the time his sight was decidedly failing he had not more
headache than usual, nor was there much tendency to sickness.
During the last two or three months he has, however, almost
always had sickness (to vomiting) once or twice a week. This
is a symptom quite new to him.

268 TOXIC AM A UROSES. [CHAP.

He applied to me first on February 8, 1869. I found that
with his left eye he could only see to spell out No. 1 6, and with
the right No. 4. The disk of the left was very pale, and of a
blue-white ; whilst the vessels were much reduced in size, the
arteries being so small that they could scarcely be traced.
The margins of this disk were quite clear. The disk of the
right was white in its nasal (inverted) half, and on the outer
part was covered with pale lymph, which concealed its edges.
The quantity of lymph, however, was very much less than is
usual in many other forms of neuritis. Although headache
and sickness have been but slightly marked during the neu-
ritis, yet it is quite certain that they have been present to
some extent.

In the left eye the margins of the disk are very definite,
not in the least jagged. There is a single minute dot of
pigment on the inner side, but with this exception, there
is no evidence of disturbance of the choroid. The retina is
quite clear at all parts. In the right there is no evidence
of choroidal implication. The retina is hazy to a slight
extent round the disk, but not to any great distance.

His smell and his tactile sensibility seem perfect.

He has sometimes seen flashes and sparks of light before
his eyes.

Reference to Plate.

Figs, i and 2 in the plate show the ophthalmoscopic ap-
pearances in the two disks of this case.

Amongst the peculiar ophthalmoscopic features of plumbic
neuritis we may mention (a) the small amount of lymph
usually present ; (V) the absence of colour in the lymph ;
(c) the absence (not invariable) of extravasations of blood ;
and (d) the early and great diminution in size of the arteria
and vena centralis. The choroid does not appear to be in the
least implicated.

CASE III. Acute lead poisoning with optic neuritis Recovery
of health, but tvith permanent blindness.

Mrs. Driscoll, set. 25, came to us at the Moorfields Hos-

XIL] TOXIC AMAUROSES. 269

pital, January 7, 1870, having been almost totally blind since
an acute attack of lead neuritis four years previously. The
evidence she gave us was the following. She went to work
four years ago in a lead factory, being at the time in perfect
health, and having never before been employed in that way.
After six months ' employment in the factory she became very
ill, had pain in the head, and severe sickness. Her illness was
attributed to her work in lead. She was confined at home for
a month with these symptoms, and became at the same time
almost blind. The sight failed suddenly and quickly. She
had no dropped wrist.- When she recovered from her illness
the state of her sight was such that she could not return to
work. Since that time (four years) she has never been exposed
to the influence of lead, and has enjoyed fair health. Her
sight has, however, scarcely improved at all.

State of vision and ophthalmoscopic appearances four years after
the attack (January 4^, 1870). She cannot distinguish a gas-
flame in a dark room, but she asserts that sometimes she can
just see light. Both eyes are alike. She is of dark com-
plexion, but pale. With the ophthalmoscope the conditions
in the two eyes are found to be exactly alike. The media are
quite clear, and the fundus is easily seen. In each the disk
is quite white. The arteria centralis is diminished to perhaps
half its natural size, the veins being much larger. The lesser
vessels, which give pink tint to the normal disk, have wholly
disappeared. Near to the disks the trunks of the vessels
are decidedly obscured, as if from past inflammation, and
there are in places white lines along their trunks. (Fig. 3
in plate.)

CASE IV. Hereditary gout increased ly lead poisoning Neu-
ritis of the left optic nerve in 1867 resulting in permanent
blindness Neuritis of right optic nerve in 1870 (still under
treatment) Interesting facts as to asymmetry of symptoms.

John West, set. 44, a painter by trade, was admitted
under Mr. Hutchinson's care at the Royal London Ophthalmic
Hospital on September 29, 1870. About three years before

270 TOXIC AMA UROSES. [CHAP.

this he had been under Mr. Dixon's care for failure of his left
eye, when he was told that he had ' atrophy of the nerve.'
This eye became at that time all but blind. He applied on
the second occasion on account of the right eye, which had
been failing- gradually for about three months.

On examination, his vision was found to be, for the right
eye, ao J. (increased by a convex glass to 7 J.) and -^j-; with
the left he could only see the light. There was contraction
of the outer part of the field in the right eye. With the
ophthalmoscope it was found that the right disk was of a
dirty grey colour, its margins ' fluffy ' and ill-defined, and the
large vessels somewhat diminished. The left disk was in a
condition of advanced white atrophy. A blue line was found
on his gums, and the gums were much wasted.

The interest of this case lay in the cause of the neuritis, and
in the occurrence in the same patient of optic neuritis, lead
colic, and gout. His family and personal history was as fol-
lows : His paternal grandfather was ' a martyr to gout ; ' he
was a stout man, a hairdresser, and drank beer. The patient's
father was a plumber, and he also suffered from gout. The
patient, a painter, had his first attack of gout sixteen years
before admission, in his left great toe ; since that time he had
had many attacks ; the left side seemed to have suffered more
severely than the right, and he stated that his left arm and
leg had often been rendered quite useless by the gout for a
month or two together. His attacks of gout had usually been
unsymmetrical ; they came on suddenly, and often at night ;
the affected joints were swollen, shining, red, and painful. He
had suffered repeatedly from colic, but never from 'wrist-drop.'
As to the cause of his attacks of gout, he said that he had
never drunk much beer, and but very little spirits; he had
always found that an attack of gout came on after he had
been ' flatting colour/ In ' flatting,' the work is done in
closed rooms, the colour is entirely lead, and is mixed with
pure oil of turpentine, a liquid which evaporates quickly,
and probably in this way carries off more vapour of lead in
a given time than the less volatile liquids used in ordinary
painting. He stated that the ' flatting ' often produces a sort

xii.] TOXIC A MA U ROSES. 271

of intoxication, especially in the men who work highest up
in the room, and is frequently followed by attacks of colic.
He himself had had no colic for five years, and he attributed
this exemption to his having' worn a moustache during that
time.

It is interesting to notice, that the eye which failed first
was on the side of the body which was earliest and most
severely attacked by gout.

One of my most instructive cases in reference to this
subject came under my notice at the Newcastle Infirmary,
during the visit of the British Medical Association last
August. The patient was under Dr. Charlton's care, and
I am indebted to him, not only for permission to examine
it, but also to make public use of its facts. Dr. Charlton
told me that he had seen several cases of loss of sight from
the eflects of lead.

CASE V. Acute lead poisoning, with imbecility and general
paralysis Double optic neuritis Complete and permanent
blindness Recovery of other functions under treatment by
iodide of potassium.

Kate Morgan, set. 19, came to Newcastle in September,
1869, and engaged herself in the lead works. Her occupa-
tion consisted in carrying white lead. In about four months
she began to suffer from symptoms of poisoning. Her bowels
became costive, and her muscles weak. Her sight also began
to fail, and in five weeks from its first defect she was quite
blind. When, in the beginning of May, she was admitted
into the infirmary under Dr. Charlton's care, her state was
most deplorable. She was wholly blind, unable to speak dis-
tinctly, paralysed in all limbs to the extent that she could
not use them, and liable to incontinence of both urine and
faeces. Her expression was that of an imbecile, and, in addi-
tion to her defect in vocalisation, there seemed also to be
inability to find her words. There was a distinct blue line
around the gums.

When I saw her in August, she had been three months

272 TOXIC AMAUROSES. [CHAP.

under treatment by iodide of potassium and sulphate of
magnesia the former in full doses. She had for six weeks
been able to leave her bed, and she could now walk well.
Her face had regained an intelligent expression, and she
could speak clearly. The incontinence had disappeared. She
remained, however, still quite blind. Dr. Page, the house-
surgeon, who supplied me with the above facts as to her case,
kindly procured me also an opportunity for ophthalmoscopic
examination. I found the disks both in the same condition
of atrophy after neuritis. They were blue-white, of a some-
what dirty appearance, and the central vessels had much
diminished in size. ' There were still traces of lymph about
the main trunks. At a distance from the disks there were
no deviations from the healthy state.

In this case it is evident that the poisoning went very near
to a fatal termination.

The girl had probably been very careless in her habits, and
had thus obtained an unusual dose of the metal. The result
of the treatment was most marked, and most satisfactory.
If we ask why the other nerves recovered their functions so
much more fully than did those of sight, we shall be obliged
to give a hesitating answer. Possibly the strength of the
sheath surrounding the optic nerves renders inflammatory
swelling more injurious to them than it is to others. It is
possible, however, that the cause of the paralysis of the limbs
was a central inflammation rather than a neuritis. As to
what had occurred in the eyes, there could be no room for
doubt, especially when we compare it with the other cases
which I have recorded.

SECTION IV.

Hypnosis and Narcosis.

The reader has seen, from much that I have already said,
that we cannot, as yet at any rate, be satisfied to take the
disk as a dial-plate which exactly and visibly indicates the
states of the encephalic circulation. At the same time, if we

xii.] TOXIC AMA UROSES. 273

can properly estimate the accidents which modify the circula-
tion of the disks, such, for example, as the correlative degrees
of intra-ocular tension, we may be able to get some knowledge
from it regarding the variations of blood -pressure in the
encephalon during the operations of certain general disorders,
of sleep, of narcotic poisons, and so forth.

Evidence of this kind, if really trustworthy, would be
invaluable, both in clinical work and in physiology. At
present, after studying many cases of general anaemia, and
of presumed cerebral congestion, such as in alcoholism, I have
been forced to believe that anaemia and congestion must be
not only considerable, but also much prolonged, if it is to
map itself out in the fundus of the'eye. At the same time,
the changes which have been observed in the eye during sleep,
by Dr. Hughlings Jackson, are of a more positive character.
The observations seem, indeed, to be conclusive, as far as they
go ; and I shall, therefore, now quote them in Dr. Jackson's
own words :

' It is scarcely necessary to say, that my reason for ex-
amining the eye during sleep was to help to form some idea
as to the condition of the circulation in the brain itself in this
physiological condition ; the retina and the brain being sup-
plied by branches of the same trunk, the carotid, and these
by the same vaso-motor nerves. We may consider the retina
as part of the brain extruded through an opening in the
skull.

' Still, I have drawn no conclusions as to the condition of
the circulation of the brain in sleep, as the subject requires
to be studied on a very extensive basis, of which these
observations can form but one part. Indeed, I study the
physiology of sleep, in order to learn somewhat as to the
circulation in the brain in certain allied pathological condi-
tions. For instance, I am anxious to know the condition
of the veins and arteries of the brain in the profound sleep,
or, perhaps more correctly, in the stupor which follows a
paroxysm of epilepsy. I have examined the retina in this
condition, and several times in cases of severe congestive
headache after a fit. The results of these and of many other

274 TOXIC AMA UROSES. [CHAP.

examinations in cerebral cases, I hope to have the pleasure of
giving in some future number.

' A girl, aged n, was admitted into the Hospital for the
Epileptic and Paralysed, under the care of my colleague,
Dr. Brown- Sequard, for hemiplegia, which had existed several
years. Of this, at the time when the following observations
were made, there was little or nothing left, and the child was
in fair general health.'

I give the following extracts from my diary as the simplest
way of recording several observations :

' Sept. 3rd. I tried, first, to examine the eye without
using atropine ; but the pupil was so small, as is usual in
sleep, that I could not illuminate the fundus. I therefore
dilated one pupil by atropine, and then examined the fundus
of both eyes when the child was awake. I found the optic
disks normal. They were equally well coloured, but not
abnormally so. I had examined her sight carefully before
dropping in the atropine, and found it perfect. When in deep
sleep, one pupil was contracted; that dilated by atropine
remained enlarged. By the aid of a very intelligent nurse,
who held up the upper lid, I was enabled to examine the
optic entrance, to which, for the present, I confine my obser-
vations. I found that the optic disk was whiter, the arteries
a little smaller, and the veins larger than in waking. The
veins were thick, and almost plum -coloured. The neigh-
bouring part of the retina, also, was more anaemic.

' Sept. 6th. The pupil was now rather small. I saw the
optic disk steadily, and could confirm my first statement. The
arteries were certainly smaller, and the veins larger than in
waking. The other parts of the optic disk were whiter, as
was also the neighbouring part of the fundus. She had been
well tired by a long romp with the nurse.

* Oct. 3rd. The pupils had regained their normal size.
I again put atropine in the right eye, and examined with the
ophthalmoscope. I carefully noted each vessel, especially the
smaller ones, and learnt by heart the position and size of
both veins and arteries, and also the condition of the optic
disk as to colour. At night I examined the eye during sleep.

XIT.] TOXIC AMAUROSES. 275

The pupil was smaller than when the child was awake, but I
luckily saw well for a long time. The optic disk was not so
red, the arteries were certainly smaller, and on this occasion,
I think, the veins were no larger, and about the same as
when the child was awake. I then roused her, and examined
under similar conditions of light, position, &c. She was
awake, but sleepy. I found that the arteries were larger;
but, on looking again, I found them smaller, as in sleep.
They alternated several times. I could not long dwell on
the disk ; and my opinion is, that the alternation was
gradual.

' Oct. 1 6th. A girl, aged n, a patient under the care of
my colleague, Dr. Ramskill. I dilated the right pupil with
atropine. In sleep, it remained dilated ; the other was con-
tracted. I saw well in this case. The child was deeply
asleep, and I had the optic disk under view for a long time.
All I can say is, that the disk itself was rather paler in sleep.
I roused the child till she was fairly awake, and the only
difference then was, that the disk was a little redder.

' The pupil, under the influence of atropine, dilated to the
fullest extent when awakened; twice the size it was when
the child was asleep. The contraction was not due to the
light only ; it was the contraction of sleep.

' Oct. 2 ist. I put atropine in the right eye, and dilated the
pupil to the fullest extent. The child is a somnambulist, and
I found her in the ward at IOP.M. in the arms of the nurse.
The left pupil (the one without atropine) was not so small as
usual in sleep. The other was as large as it was when she
was awake. She was apparently asleep, however. I ex-
amined the eye, and then fairly awakened her, by pinching
and making her speak and getting her to look in certain
directions. I again examined her eyes, when she had gone
to sleep in bed. I feel convinced that the arteries were
a little smaller, and the veins larger. I saw well, and for
some time.

' Oct. 24th. Atropine as usual. I saw well ; the disk was
whiter, and the arteries smaller.

* I ought to observe, that in all these examinations the dif-

T 2

276 TOXIC AMA UROSES. [CHAP.

ference in the size of the arteries and in the coloration and
the optic disk during- sleeping and waking- was but slight.'

I have been unable to repeat these observations. In the
few cases where an opportunity has offered itself, the uplifting
of the eyelids and the glare of the reflected light always
awoke the person to be watched. The way in which Dr. Jackson
speaks, however, and his well-known caution as an observer,
command the greatest weight for his statements; moreover,
we must remember how closely these results accord with those
obtained by Hammond and Durham. If cerebral function
depend upon an adequacy of arterial blood, this function can-
not be carried on under a deficiency of arterial blood, whether
such deficiency be due to emptiness of the vessels, or to their
repletion with blood unaerated.

So no doubt we have sleep, artificial or natural, due to
anaemia; and sleep, artificial or natural, due to venous con-
gestion of the capillaries.

It may be not only very interesting to us as physiologists,
but very important to us as therapeutists, to classify our
agents according to the two ways in which they act upon the
brain; and to classify in like manner the various states of
sopor not induced by drugs, in which our patients may be
found. May not coma be thus contrasted with true sleep,
and bromide of potassium with alcohol ? I am led to these
reflections by the fact discovered by Dr. Lewizky, of Kasan,
and published in Virchow's c Archives V that bromide of
potassium causes retinal anaemia.

As Dr. Lewizky's observations seem to have escaped the
notice of ophthalmologists, and as I have verified them in
two patients who were under the influence of large doses of
bromide of potassium, I extract the following lines from his
article.

Dr. Lewizky says, after describing certain observations
upon the vessels elsewhere, and showing that bromide of
potassium causes a narrowing of the vessels : ' On a rabbit
in which I trepanned the top of the skull, and observed the

7 Vol. 54, Pt. ii. p. 193, part of article ' Ueber die Wirkung des Brom-
kalium auf das Nerven-System.'

xii.] TOXIC AMAUROSES. 277

vessels of the pia mater,, it seemed to me as if the membrane
became paler and some of the fine vascular branches dimin-
ished. In some ophthalmoscopic observations which I made
upon the vessels of the retina with regard to the influence
of bromide of potassium it was quite evident (ganz klar) that
these vessels grew narrower 8 .' This is very coherent with
Dr. Hughlings Jackson's observations, and with those of
Hammond and Durham. Mr. Durham also trepanned the
skull of a dog, under chloroform, and watched the vessels of
the pia mater. So long as the chloroform was being applied
the veins of the membrane were distended and overfilled;
when the dog fell asleep, the membranes became pale, the
vessels fading and contracting. On arousing the animal, the
surface of the brain again reddened, and pressed through the
opening.

Hypersemia of the retinal vessels may be a sign of general
hypersemia of the encephalic vessels, or it may be a sign of
some obstruction affecting the ophthalmic veins wholly or
chiefly. In the former class we must place the hyperaemia
which is said to be due to some narcotics. It seems very
probable that narcotics proper produce their effects by a venous
hypersemia of the brain ; that the retinal vessels are very
heavily congested during states of sopor and coma is, I think,
made clear. M. Bouchut speaks in the most certain way of
having witnessed this kind of action in the retinal vessels.
In many cases he watched the action of chloroform on the
retina during the inhalation of the drug, and in all he found
a very marked injection of the fundus, with increase in the
number and size of the veins. In some cases he noticed a
capillary congestion and effusion masking the whole of the
papilla and throwing a veil over it.

In one case the effects were so marked that M. Cuinier, an
experienced observer, could scarcely believe in the reality of
what he saw. In the ' British Medical Journal' for May 27,
1871, a death from chloroform is recorded. After death,

8 It is not important here to distinguish whether the contraction of the vessels
be due to antecedent diminution of the activity of cerebral tissue, or whether
the latter be due to a contraction of the vessels.

278 TOXIC AMA UROSES. [CHAP.

Mr. Couper found the retinal veins greatly distended, but
whether Mr. Couper considered this as a common sign or as a
fatal sign, the deponent says not. Bouchut noted somewhat
different effects on the administration of belladonna and
opium. In these latter cases the capillary circulation is little
affected, the disk seeming unchanged, while the veins are
distended. This is very like what Dr. Jackson saw in natural
sleep, small arteries, that is, with large veins ; so that opium
sleep may be, perhaps, genuine anaemic sleep, and not the
sleep of capillary congestion. In a paper in the * Practitioner'
(January 1871, p. 15) Mr. Goodhart states that he noticed the
same change in the vessels of the retina on the administration
of nitrite of amyl, the arteries, that is, were diminished in
size, while the veins became dilated and varicose. Richardson
has noticed the same thing, also, in the capillaries of the
frog's foot. I have neither had the time nor favourable
occasions for the repetition of these experiments ; when taken
up, they must be carried out very thoroughly, and the results
of the administration of many drugs noted and compared
with each other, with the effects of natural sleep, and with
states of coma from disease. However, my friend and former
pupil, Mr. Aldridge, now one of the resident medical officers
of the Wakefield Asylum, has taken up this subject with con-
siderable industry, and I am enabled to quote the following
conclusions from a paper which he is now publishing in the
first volume of the West Riding Asylum ' Medical Reports J
for 1871. Mr. Aldridge has investigated the effects upon the
retina of the following drugs :

' i. Potassium bromide. The effect on the circulation of the
epileptic was not seen for some two months, and then a
marked change was noticed in the calibre of the veins.
Where they had formerly been dilated they became much
reduced in size, and the capillary tint of the disk lessened ;
there was no change in the arteries. In fact, the state of
passive hypersemia which previously existed had become
changed, and a more normal and active condition of the cir-
culation induced. From these facts I concluded : " It would
appear that the reduction in the amount of hypersemia is not

xii.] TOXIC AM A UROSES. 279

induced rapidly as a direct effect of the action of the bromide
on the blood-vessels, but is rather due to the diminution of
the fits which give rise to the constant congestions."

' 3. Ergot. Was used in cases of epileptic mania 9 . The con-
dition of the retinal circulation before its administration was
one of great and active hypersemia 10 . The drug did not cause
any immediate and marked change, but in a few days or a
week almost all signs of active congestion had subsided. In
the same cases when the medicine had not been given the
state of mania had lasted for several weeks, and the congestion
of the retina had continued for the same length of time.

' I also gave the ergot to an old epileptic who had never
been treated before. In the first instance, before the medicine
was given, there was great passive congestion of the retinal
circulation. In twenty-four hours there was a slight change
observable in the arteries, their calibre having become re-
duced, and at the end of a week, although no change was
observed in the arteries, the capillary tint had become paler,
and the veins were not so dilated ; at the same time, the fits
had become reduced considerably in number.

' 3. Chloral. Twenty-five grains were given to a patient who
had never taken the drug before. It produced no apparent
effect either in her general condition or in her retinal circu-
lation, which was examined every hour for six hours after the
drug had been taken. In another case, thirty grains were
given to an epileptic who was slightly excited, and whose
retinal circulation was abnormally active. In one hour no
effect, either general or local, could be observed ; she then
took a second thirty grains, and soon afterwards became
quiet, drunk, and sleepy. At this period a very slight reduc-
tion in the size of the arteries was observed, and the disk was
slightly paler. She was now put to bed, and in about an
hour, when she was in a very sound sleep, the retinas were
examined. The arteries had become slightly contracted, and
the disk was paler than it had ever been. She was roused up

9 Vide article by Dr. Crichton Browne in the ' Practitioner,' June, 1871.
T. C. A.

10 Vide p. 83 of this volume. T. C. A.

280 TOXIC AMAUROSES.

by walking about the room, and again examined. The tint
of the disk had deepened, and the whole circulation had
become more active. In two or three cases the same condi-
tions were observed after taking the chloral hydrate. ( Vide
" Observations" of Dr. Hughlings Jackson, p. % 73.)

* 4. Nitrite of amyl* A large number of cases were ex-
amined, and the results were found to be the same in almost
every case. At the period of deepest flushing of the face and
neck, the retinal circulation was found to be in a state of
active hypersemia, the arteries being notably increased in size.
This appearance was, however, of short duration, lasting about
the same length of time as the flushing of the face.

' 5. Nitrous oxide gas. The effects produced upon the retinal
vessels by this drug resembled closely those produced by the
nitrite of anayl, but were of rather longer duration. The
patients were examined during the stage of greatest flushing
of the face. In Dr. Mitchell's own person the effects were
best seen, as the disk became of such a deep red colour as
to be almost indistinguishable from the surrounding choroid.
I was unable to get a view of the retina at the time when the
face had a pale, livid appearance.

' I should state that the cases where chloral was given did
not manifest the flushing which is sometimes seen to follow
the exhibition of the drug. 5

I have only to add a hope that Mr. Aldridge will pursue
these most interesting- and important investigations.

CHAPTER XIII.

THE EFFECTS OF MENSTRUAL DISORDERS UPON
THE OPTIC NERVES.

IT seems scarcely doubtful that women present themselves
at eye-hospitals with disorders of vision which appear to be
attributable to menstrual disorders. On the other hand, I
have examined women innumerable, amenorrhagic, dysme-
norrhagic, and hypermenorrhagic, until it seemed to me a
mere waste of time to look farther, and yet without discover-
ing any such coincidences.

Pagenstecher 1 speaks very strongly in favour of a connec-
tion between blood losses and neuritis or atrophy. He says,
that in many cases and during a long period he has had occa-
sion to diagnose changes in the retina as due to piles, and
also to ' serious disorders' of the menstrual function. Three
times he has seen atrophy of the optic disk supervene after
menstrual disorders of long standing. In one of his cases,
neuro-retinitis descendens is attributed to haemorrhoids. For
my own part, I feel great hesitation in accepting the asser-
tion of a causal connection between such events. I have
certainly found anaemia, and very marked anaemia, of the
disks in such cases ; moreover, in extreme anaemia, as I have
said, we often find slight oedema also, but I have never
seen neuritis or atrophy. I am far from hinting that

1 ' Klinische Beobachtungen,' 3 Heft, Wiesbaden, 1866, pp. 67 and 75.
Mooren also takes a similar view of the causation of many cases of neuro-
retinitis, 'Beobachtungen,' pp. 294-297.

282 EFFECTS OF MENSTRUAL DISORDERS [CHAP.

Dr. Pagenstecher has mistaken anaemia for atrophy ; he is too
skilful an observer to admit any such source of error ; but
I do mean to say, that cases of atrophy of the disk and of
neuritis often crop up at ophthalmic hospitals, in which no
such cause exists, nor any other cause which can be described,
and I think it very likely that some of these may be credited
to haemorrhoids or menstrual losses, when the latter are really
independent coincidences.

A very interesting case went the round of the foreign
journals about two years ago, in which haemorrhagic neuro-
retinitis followed haematemesis. It is probable, however, that
the two events were the common consequents of some strange
affection in the medulla and upper cord. The lady was seized
at first with an agonizing pain at the back of the neck, and
the haematemesis and retinal mischief succeeded it.

That, as a general truth, inanition or large losses of
blood enfeeble vision as they enfeeble hearing and touch, is
scarcely worth asserting; and this debility seems to follow
protracted suckling more commonly than any other drain.
Many women have feeble vision, or even loss of vision, after
an unusual drain of this kind. Deficient supply of blood from
the heart is probably one cause, for in these women we find
the heart pumping away with a great pretence of vigour, but
making little effect upon the distal arteries. The praecordial
movement is perhaps the labour of a distended right ven-
tricle, the left ventricle wanting proper blood-supply; or it
may be that the left ventricle, like the carotids, loses tone in
such cases, and throbs painfully: when this occurs, in con-
nection with enfeebled or capricious vision, the case is called
one of amaurosis from congestion ! The periodicity of nerve
changes is well shown in states of optic anaemia from drain,
the nerves at frequent times going quite to sleep, the patient
falling blind for awhile.

Here I may refer also to those other cases, in which
* amaurosis' has been credited to worms (vide Appendix, cases
7 and 12), to the suppression of eruptions (vide case 25), to
excessive or diminished secretions, and the like. These cases
are generally recorded in a curious, rather than in a scientific

XIIL] UPON THE OPTIC NERVES. 283

temper, and, like ghosts at cock-crow, seem to show a re-
markable tendency to evanescence when submitted to the
light of the ophthalmoscope. They mostly belong to the
category of perverted sensations, or perverted perceptions,
which are common in all parts of the nervous system, and
are themselves of but little moment.

CHAPTER XIV.

EMBOLISM OF THE CENTRAL ARTERY OF THE RETINA
AND ITS BRANCHES 1 .

IN the first instance, I had not intended to include this
subject among those treated in this volume; but, on subse-
quent thought, I venture to do so. Embolism of the artery
of the retina is indeed a purely local event, and has its origin
in an accident, rather than in any special constitutional state.
It is a process, however, which has interested me very much
as a physician; and I think, therefore, that it will interest
my brethren, as being a specimen, and a visible specimen, of
an event which frequently occurs in organs under medical
charge. To see this process, and thus to be enabled to reason
upon it when it occurs invisibly, is very valuable help. I
shall therefore describe what is seen of arterial embolism in
the eye, and shall make some reflections upon its phenomena,
which have, I think, bearings of a general and important
kind. The discovery and examination of the phenomena of
embolism were made about sixteen years ago, and, although
much was done to illustrate the discovery by our own Kirkes
and others, yet the discovery itself is, I believe, to be attri-
buted to Virchow 2 . The first observer who minutely de-
scribed the ophthalmoscopic appearances in the eye in such

1 Liebreich, Atlas,' plate viii. figs. 4 and 5.

3 Vide ' Gesammelte Abhandlungen,' 1856, pp. 539 and 711, where two
examples of embolism in the eye are recorded. Vide also his ' Archives,' vol.
ix. Pt. ii. p. 307, and x. Pt. ii. p. 179, 1856.

EMBOLISM OF THE CENTRAL ARTERY, &c. 285

cases, was the great Von Grafe, whose first memoir appeared
in the Archives of Ophthalmoscopy for 1859. Liebreich soon
followed with an account of numerous cases, and he has now
personally observed no less than sixteen cases. Dr. Knapp, of
New York, has lately collected all the cases of embolism of the
vessels of the eye which are on record, and has added a very im-
portant case of his own, to which I shall have to make especial
reference. No one has better described the phenomena than
has Von Grafe in his first case (loc. cit.\ and I shall there-
fore use his own words in description. I have myself met
with three cases of the kind, one of which was shown to
me by Mr. Teale some years ago. As might be expected,
there is great uniformity in the phenomena of the cases
on record.

On Dec. 17, 1858, a patient presented himself before Grafe
who had suddenly lost the sight of the right eye a week
before, at which time it was ascertained that he was suffering
from traumatic endocarditis. While at work he perceived a
cloud to form before his right eye, giving misty outlines to
all objects. The field of vision then rapidly contracted, and
in a few minutes the perception even of light was quite gone.
On examination it was found that the right eye was abso-
lutely blind, and that its iris only contracted sympathetically
with that of the other eye. On applying the mirror the
media were seen to be quite transparent, but the disk was
very pale and its vessels reduced to a minimum. The prin-
cipal arterial branches beyond the disk were also like fine
lines upon the retina, the farther branches having quite dis-
appeared. The state of the veins differed from that of the
arteries, smaller indeed they were than normal in all places,
but towards the equator they increased in size. The left eye
was normal in every respect. Now this was not atrophy of
the disk, for in no form of atrophy have we such a relation
between veins and arteries ; and, moreover, the papilla
though pale was quite transparent, and not diminished in
volume.

Grafe then distinguishes between the inferences of an
obstacle inside the retinal artery and outside of it, and again

286 EMBOLISM OF THE CENTRAL ARTERY [CHAP.

of a rent of the artery, deciding in favour of the first hypo-
thesis, which was subsequently confirmed by an autopsy. He
also points out that the central artery must be the seat of the
plug, as if it were above that artery there would be some
interference with the choroidal circulation, which was not the
case. When seen a week later, the region of the yellow spot
was no longer normal. The central part of the retina began
to veil the tint of the underlying choroid, and this veil soon
became more evident as a distinct greyish white opaque
infiltration. The foramen centrale appeared, on the other
hand, to be surrounded by a patch of deep cherry-red ; it was
about one-quarter the size of the disk, and was placed in the
midst of the infiltration. This intense red colour was shown
subsequently by Liebreich not to be hsemorrhagic, but to be
an illusive effect of contrast. On examining the infiltrated
parts in large images it was found not to be uniform, but to
present a number of whitish points, which, to judge from
other investigations, would seem to be aggregations of fatty
granules. Ultimately, some perception of light returned in
the eye, as a little collateral circulation was perhaps estab-
lished ; but the great part of the affected retina, with the
disk, underwent fatty degeneration.

Such were the phenomena in the classical case, and there is
little to add to them. It will be seen in all such cases, as we
should expect from the blood-supply of the retina, that this
once cut off, there is little hope of any valuable collateral
circulation being established. If we compare this case of
occlusion of the main stem of the arteria centralis with Dr.
Knapp's case, in which one intraocular branch only was
affected, we find that in it blindness and opaque infiltration
also occupy the part affected, but the veins of the same part
are enlarged and tortuous.

There were also in Knapp's case numerous apoplectic spots
in the affected region, chiefly around small venous twigs, or
on both sides of the larger ones. Another very remarkable
peculiarity in Knapp's case is the recovery of the normal
calibre in the distal parts of the occluded artery. Dr. Knapp
accounts for this by supposing ' that the sudden increase in

xiv.] OF THE RETINA AND ITS BRANCHES. 287

calibre of the retinal artery may fairly be accounted for as the
place of junction of a retinal and a ciliary artery;' and he
adds, ' the blood seems to have been driven out of the arteries
by the contractility of their walls.' Now this brings me to a
point upon which I would lay some stress, as it is of great
interest and importance in estimating the effects of arterial
embolism elsewhere. The point is this, that the venous dis-
tension and the haemorrhages are probably rather due in part
to the action of the heart, which falls with a stress upon the
open vessels, which is excessive in proportion to the lessened
area over which its action is distributed. Secondly, that
the fulness of the distal branches of the artery and the
distension of the veins associated with it are due directly
to a palsy of that extent of the walls of the occluded
artery which lies beyond the plug. This latter fact, which
has bearings of a most important kind upon the phe-
nomena of ligature, and *I think of embolism also, was estab-
lished some years ago by Brown- Sequard, whose observations
have not in this instance attracted the attention they deserve.
In embolism of the arteria centralis retinae, the opportunities
for collateral re-establishment of blood-supply are too slight
to enable us to reason exactly from it to other arterial regions
more fortunately placed in this respect ; but the phenomena of
the plugging of one branch of it, as described by Dr. Knapp, give
us exactly what we want in order to reason, let us say, to the
phenomena of embolism of the Silvian artery ; in which case
we have also one branch of a system blocked up, and that one
a branch which is but tardily supplied, as the branch in
Knapp's case was tardily supplied, by associated but distinct
members of the same system. Brown-Sequard's observa-
tions were made by him only in the case of ligature. He
says, in a recent communication 3 , that ligature of an artery
necessarily paralyses the vasal nerves which course along it,
and consequently causes flaccidity of the distal portions of the
vessel tied. The heart's impulse remaining the same, the

3 ' Arch, de Physiologie Norm, et Path.' No. 4, 1870, pp. 318, 319 ; where he
refers also to statements by Prompt and Moreau, ' Comptes Rendus de la Soc.
de Biologic,' 1868, p. 233, which I also have before me.

288 EMBOLISM OF THE CENTRAL ARTERY [CHAP.

blood is forced accordingly into this district of least resistance,
there being ever a correlative venous reflux in cases where
direct anastomatic supply is difficult. He found even when
he cut off all arterial supply to an organ (such as the kidney),
save one vessel, that on tying this vessel the organ became
congested by venous reflux. I need not say how direct an
application th'ese facts have in cases of ligature, say of the
carotids, and how they illustrate the previously obscure facts
of hypersemia in parts beyond ligature. For instance, I was
reading but the other day an interesting account, by Mr.
Chatto, of a paper by Prof. Hueter on Arterial Transfusion 4 ,
in which the syringe was ligatured into the posterior tibial
artery. Prof. Hueter remarks, that on transfusion, although
extravasation has not been observed, yet the fine vessels
undergo great expansion, the papillary bodies being filled
with more blood than even in a condition of inflammation.

Now, it embolism has anything like the same effect which
ligature has upon the distal branches of an artery, we have
at hand a very interesting explanation of certain well-known
and hitherto puzzling phenomena of these cases ; such, for
example, as the congestion, more or less venous, of the parts
beyond the plug, and the strong tendency to haemorrhage.
It has occurred to me that the gangrenous character which
supervenes in the inflammation of parts, such as the penis,
where the inflammation causes plugging of main arteries,
may be due to this kind of vaso-motor paresis 5 . A plug
inside an artery is not, of course, so efficient a paralyser of
its associated vasal nerves as a ligature would be; but the
distensile force stretching the arterial coat behind an obstruc-
tion suddenly formed, is likely, as it seems to me, to have a
similar, if not a co-extensive, effect.

In this volume I have to deal with the lights which the
ophthalmoscope throws upon nervous disorders ; and in the
present chapter, therefore, I have to consider what light this

4 'British and Foreign Med. Chir. Review,' July, 1870, p. 272.

6 And this would explain the success which has followed the practice
of my colleague, Mr. S. Hey, who unloads the vessels in these cases by free
local bleeding.

xiv.] OF THE RETINA AND ITS BRANCHES. 289

instrument throws upon that sadly common accident em-
bolism of the Silvian artery. I considered this question some-
what fully in an article in the * Medical Times and Gazette*
of the 3<Dth of April, 1870; and as I have little to add
to what I then said, I shall reprint that article here. It
will be seen from the opening remarks, that I applied the
ophthalmoscope to test certain statements of Prof. Niemeyer,
which had appeared in the same journal a few weeks before.

On the Symptoms of Embolism of the Silvian Artery, and
their Causes.

I feel there is some presumption in my coming forward to
discuss any points of Professor Niemeyer's lecture ; my only
excuse is, that these cases of Silvian embolism have for some
years been a favourite study of my own, and that I have
certain definite opinions concerning the phenomena of them,
which opinions are somewhat different from those of Professor
Niemeyer 6 . I hope I am justified, therefore, in taking the
present occasion for a brief mention of some of them. At
the same time let me express my sense of the great value and
importance of Professor Niemeyer's lecture, and let me parti-
cularly refer to his account of the very interesting collateral
phenomena of splenic embolism in the case which he records.
I do not think we in England inquire sufficiently into any
history of pain in this region, or of shiverings, or that we look
carefully enough for enlargement of the spleen with or with-
out tenderness. His observations, again, on the discovery of
encephalic embolism and thrombosis as pathological facts are
very interesting, as they are in direct refutation of such stric-
tures as that of Nelaton, which has attracted so much atten-
tion of late. I mean the absurd accusation against ' mikro-

6 While these sheets were in the press we had the sad news, first of Grafe
and afterwards of Niemeyer, that their work was done. My first impulse was
to strike out the controversial parts of the following paragraphs, but on
second thoughts it seemed best to leave them as they stand. By none could
it be more proudly said, ' Non omnis moriar,' and for us the greatest part of
the master still lives.

U

290 EMBOLISM OF THE CENTRAL ARTERY [CHAP.

scopische Spielereien,' which, according to Nelaton and others,
have the tendency to encourage a beetle-eyed method, and to
disintegrate all large conceptions of clinical phenomena. In
encephalic embolism we have a discovery which was bred by
this new spirit of minute research, which, however, is not a
microscopical discovery at all, but one which was open to the
naked pathological eye, and which was discovered less by
poring among the tissues than by the suggestions of clinical
phenomena themselves. So that in this, as in hundreds of
like instances, the microscope is the companion of accurate
and discriminating clinical observation, and not of petty
curiosity.

The point to which I wish rather to refer to-day is that of
the phenomena of consciousness and their causation. In the
case of Silvian embolism, which Professor Niemeyer records,
unconsciousness was a marked symptom, and he speaks of
unconsciousness as a common symptom of this disorder.
Indeed, he refines upon the diagnosis between embolism and
haemorrhage, and considers that the loss of consciousness in
both is one of the resemblances which tend to confound the
two kinds of mischief; so that the ultimate diagnosis is
rather to be inferred from the less direct evidence of the
patient's- age and the condition of the heart. In his subse-
quent remarks upon the pathology of the affection, Professor
Niemeyer offers an explanation of this unconsciousness, and
he refers it to an oedema of the parts which suffer to an
oedema, that is, of the mesocephalic ganglia and their neigh-
bourhood, which presses upon the cerebrum. This is a very
important question, and it is one upon which the diagnosis
of Silvian embolism more or les,s depends.

To take the symptoms first : it is certainly contrary to my
experience of cases carefully watched and investigated to sup-
pose that unconsciousness, or what I may call mental or
cerebral apoplexy, occurs in them to any marked degree.
These cases of embolism are not uncommon either in our
waiting-rooms or in our museums, and I have generally six
or eight under my own care among hospital patients and
elsewhere. Now it is a remarkable and important fact, that

xiv.] OF THE RETINA AND ITS BRANCHES. 291

in my own cases I rarely get a history of complete uncon-
sciousness. I very rarely find, that is, a history of coma or
semi-coma,, unless it be of very short duration. In many well-
marked cases with complete or almost complete hemiplegia,
I have satisfied myself, after careful inquiry, that there has
been no actual unconsciousness at all, but rather shock and
bewilderment. To speak pathologically, there has been in
such cases no evidence of more than momentary pressure. For
example, on turning to my notes, I find that a young woman
suffering now from marked and obstinate hemiplegia, and
from all the symptoms of left Silvian embolism and from heart
mischief, never really lost consciousness at all. She had risen
from bed but a few minutes or moments, when she fell, and
was raised up hemiplegic; she was * dazed,' but remembered
indistinctly what had passed, how her friends came about her,
how her husband lifted her, and how she woke from a sort
of confusion to find her right side useless and her speech
impaired. To take a second case : a woman was engaged in
household work, ' a sickness and fainting came over her/ but
she was able to reach her chair ; she seems then to have been
' lost' for a few seconds, from her daughter's account, but soon
recovered consciousness, remaining, however, hemiplegic of
the right side. Another woman was standing on a chair to
reach something above her, when she fell to the floor hemi-
plegic 7 . Again, Mrs. H., about 40 years old, and of healthy
appearance, had rheumatic fever seven years ago, and has
now heart mischief. Nine months ago, on rising from her
breakfast-table, felt bewildered and fell. Unfortunately, she
was at the moment alone. She arose again, feeling in a dream,
and again fell. Three times she essayed to stand and fell, but
on the third occasion she managed to fall into a chair, and
ring the bell. She is sure she never lost consciousness, but
was bewildered and ' dazed.' When her friends came in, they
found her quite hemiplegic on the right side, and also speech-
less, or nearly so, but not unconscious. She is still severely
paralysed on the right side, and talks with much hesitation.

7 Embolism often occurs after or during some effort, or during an attack
of palpitation.

U 2

292 EMBOLISM OF THE CENTRAL ARTERY [CHAP.

There was but transient unconsciousness. The same stories
I find also in the histories of male patients attacked with
left Silvian embolism. I am told of their being ' dumb-
foundered/ ' faint,' ' lost for a few minutes/ and the like, but
seldom really comatose or stertorous. I lately saw a very
curious case of this kind near Manchester, in consultation
with Dr. Eason Wilkinson and Mr. Mellor. A healthy young-
man, having no syphilitic antecedents, went down to his office
in Manchester, and while there made many strange and
inappropriate entries in his books. On returning home to
dinner in the middle of the day, he was observed to be
twitching his face, especially on the right side, and to speak
indistinctly. During dinner, also, he made grimaces, and
was rather confused in mind and speech. He also often let
fall his knife from his right hand, so as to attract attention.
On starting to return to Manchester, he became unable to
hold his umbrella in his right hand ; his leg also gave way,
and he was brought into the house again, completely palsied
on the right side, and also completely or almost completely
aphasic. In this state I saw him. We all agreed, without any
ultimate ground for doubt, that this was a case of embolism,
in which the plug was at first but partially impacted, and pro-
bably acting for a few hours as a ball valve in the arterial pipe.
Here we are supported by the evidence of the ophthalmoscope,
which proves that some hours have elapsed in some cases be-
fore the plug became fixed, before the arteries were quite oc-
cluded, and before vision was wholly lost. In all these cases,
I refer, of course, to embolisms of the main artery with grave
persistent hemiplegia, and some speechlessness ; not to embo-
lism of smaller branches, on the one hand, or of the internal
carotids or anterior cerebral arteries on the other hand. In all
cases of simple Silvian embolism, loss of consciousness seems
to me to be far from a prominent symptom. Still, in some
cases, it does occur; but these cases form a small minority
of the whole : in them, I believe, there is some collateral
haemorrhage in addition to the embolism 8 . Now, this absence

8 Embolism may, of course, be followed soon by ' red softening' in the
hemisphere, when there "may be serious disorder of consciousness.

xiv.] OF THE RETINA AND ITS BRANCHES. 293

or slightness of the unconsciousness is very remarkable when
we compare it with a haemorrhage of like extent. A haemor-
rhage into the corpus striatum sufficient to reach the speech
districts, and injuring the corpus itself so far as to produce
grave and abiding hemiplegia, is always attended with de-
cided, if not with serious, coma, with coma lasting, perhaps,
for several hours, and accompanied with more or less stertor.

So far for the symptomatology: let us now inquire into the
pathology of the affection. Embolism occurs in one place
where we can see it namely, in the central artery of the
retina ; and I have been in the habit of collecting all the ob-
servations I can find of this disorder as illustrative of the
same process in the encephalon 9 . I have also had the oppor-
tunity of seeing three cases one which was shown me by
Mr. Teale, another which I watched myself for a long period,
and a third, which, however, was of somewhat doubtful origin,
but probably embolic. Now, the phenomena in these cases,
if the plugging be fully established at once, are

1. Instantaneous, or almost instantaneous, loss of function.

2. Sudden emptiness of the arteries and capillaries, and
more or less of the veins.

3. CEdema of the parts deprived of supply, which oedema
comes on gradually, and, in cases seen early, amounts to little
more than a slight haziness around the yellow spot.

4. A tendency in the later stages to haemorrhages from
collateral vessels (peripapillary and choroidal).

5. Ultimate thickening of the adventitia of the vessels
and fatty degeneration of the retinal tissue, with deposit of
cholestearine (Schweigger, Augenspiegel).

I think we may fairly assume that the changes in the
encephalon are of the same kind namely, sudden emptiness
of the arteries and corresponding venules, with some momen-
tary deficiency in the contents of the sinuses, cedema of the
affected parts, tendency to collateral haemorrhages, and in-
stantaneous loss of function. One condition, however, which
we have not in cases of embolism of the main stem of the

9 Compare especially Liebreich, 'Deutsche Klinik,' 1862, No. 50; bis
' Atlas,' loc. cit., and previous pages of this chapter.

294 EMBOLISM OF THE CENTRAL ARTERY [CHAP.

arteria centralis retinse, but which we have in Silvian embo-
lism, and which we have to some extent and may see in the
embolism of a secondary retinal artery, as in the case of
Dr. Knapp already mentioned is this, that there is a
possibility of some supplementary circulation. Though this,
even in the Silvian district, is far less than, say, in the district
of the mesenteric artery, yet it must have some effect, and an
effect of the kind I have anticipated on a previous page. We
shall have, as in Dr. Knapp's case of the retina, quick filling
of veins and of the distal branches of the Silvian artery with,
blue or bluish blood; and we may also have, as in Dr. Knapp's
case, a number of small hsemorrhages.

Now, such being the pathological conditions, how are they
related to the symptoms ? Instantaneous loss of function of
course is itself a symptom, and I merely mention it in the
present connection, because we are enabled to see from the
changes in the eye, which we can follow, that the loss of
function is immediate. The promptness and severity of sub-
sequent hsemorrhages seem to depend upon the strain on col-
lateral vessels, and on the degree of the vasal paresis. For
example, in embolism of the mesenteric arteries, I believe,
abundant haemorrhage always occurs. In the eye, on the con-
trary, where collateral vessels are few and small, hsemorrhages
are few and small. In the encephalon we more frequently
find a tendency to haemorrhage ; and haemorrhage, when it
occurs, produces by its pressure anaemia and loss of function
in neighbouring parts, over and above loss of function in the
parts directly cut off from the circulation. There was this
tendency to haemorrhage in the case recorded by Professor
Niemeyer. Lastly, as to the oedema. To this, Professor
Niemeyer attributes the unconsciousness, supposing that it
is the agent of pressure upon the hemisphere, or brain proper.
Now, a study of embolism in the retinal artery shows us that
the oedema, so far from being immediate, creeps on somewhat
slowly 10 , and that a patient seen soon after the accident pre-
sents but little oedema. This oedema occurs, then, not as a

10 ' Einige Stunden ' (Bles.sig), or, ' am folgenden Tage nach Beginn der
Erkrankung' (Liebreich).

xiv.] OF THE RETINA AND ITS BRANCHES. 295

' serous apoplexy,' but as a gradual infiltration or soaking of
the tissues, which is in some way consequent upon the empti-
ness and paresis of their vessels. The oedema may also be
partly due to a change in diastatic relations or in vascular tone ;
but, I think, in the encephalon it is chiefly compensatory, and
is to be likened to the emphysema which compensates atelectasis
in the lung. An arterial region is emptied, collapse follows,
and we sometimes find, in addition to local oedema, an excess
of fluid, which may be blood-tinged, in the subarachnoid spaces
or in the ventricles, with or without an evident accumulation
of venous blood in neighbouring parts. The greater degree
of exudation is not seen, I think, in embolism of the lesser
vessels, but is recorded in embolism of the carotids.

(Edema then is, I believe, a process subsequent to the plug-
ging, and is not a cause of pressure upon surrounding parts,
but is rather a support to parts which are in danger of collapse.
Haemorrhage, again, is, in the eye, a late process, and never
simultaneous with the embolism. I believe the same is true,
or almost true, also of the encephalon. Haemorrhage, there-
fore, is not often a prompt cause of pressure upon the hemi-
spheres in these cases ; so that both clinical and pathological
experience lead me to deny that unconsciousness is a grave
symptom in Silvian embolism, and to maintain that in this the
symptoms of Silvian embolism differ from those of encephalic
haemorrhage in the same region and of equal extent.

I admit that, although in some cases of Silvian embolism
there is no unconsciousness at all, unless a transient bewilder-
ment be called unconsciousness, yet in many cases there is no
doubt an interval of unconsciousness, though far less than in
a case of haemorrhage of equal extent. What is the cause
of this transient unconsciousness ? Now, as this symptom is
sometimes absent, and, if present, is present in very various
degrees, there are probably two or more causes at work which
may alone or together throw the action of the hemispheres or
cerebrum proper into temporary abeyance, the caprice of the
symptom being probably due to some want of uniformity in its
causation. I believe that unconsciousness may be due to one
or all of the following causes :

296 EMBOLISM OF THE CENTRAL ARTERY, $c.

1. That degree of venous reflux and fulness of the distal
vessels which we have seen in the eye in Dr. Knapp's case,
and to some extent in other cases also, and which is due to
a certain degree of vasal paresis caused by the local pressure
of the plug.

2. That shock, which in the whole encephalon seems by
a certain sympathy, as it were, to echo the shock of sudden
injury to any one of its principal parts. It is a matter of
common experience in medicine, and likewise in experimental
pathology, that partial injuries, if slowly induced, may be
unfelt by neighbouring and connected parts ; but that, if
suddenly induced, they are followed by great disturbance
of such other parts. This disturbance is shown in losses of
sensibility, in rotatory movements, in vertigo, and the like.
In this way, it seems to me that the sudden collapse of
the mesocephalon in Silvian embolism may be echoed in the
hemispheres, and thus give rise in them to some transient
molecular disturbance and some transient change in corre-
sponding function. It seems certain that the sudden emptying
of important blood-vessels cannot take place without collapse
in the parts cut off, and dislocation in the parts which are
near them,

3. There must be a moment of increased tension in all the
encephalic arteries at the time of the plugging of the Silvian
artery. The next heart-stroke and the next systole of the
carotids is expended upon a smaller extent of surface than
before. In cases where the vessels are diseased, prompt
haemorrhage might occur in this way, and would occur rather
in parts whose normal resistance is lessened in the parts,
that is, which surround the Silvian region, and which, by the
collapse of this region, are deprived of their normal support.
But it is merely to the increased fulness of the arteries in the
hemisphere, and in the membranes above and beyond the
Silvian region, to which I would especially refer as a con-
sequence of the temporary increase of strain, and as likely to
produce a momentary effect of concussion when the extra blood
is thrown into them from the carotid, whose calibre remains
unchanged.

CONCLUSION.

AND now, kind reader, I have done, and it only remains for
me to conclude, gracefully if I can, but in whatsoever way
to conclude. I say kind reader, but I much fear the kind
reader is dead ; I fear it, often wondering and hoping that he
may still live that courteous gentleman who bought our
books, read every line of us, welcoming our truths, ever kind
to our faults, and pulling off his hat if he thought it well to
correct us. For his own sake, indeed, I sometimes trust that
he is gathered to his rest amid the eternal tranquillities of his
more and more gentle and learned forefathers. If he now
live, his courteous forbearance must be greatly exercised by
us modern scribblers, and his fine ways must be grievously
hustled in this growing world. Yet, if he be dead, I sadly
think, then there is none to read these lines, for none else
would bestow himself so far upon me ; none else would set
me so far upon my journey; there is no other, and I will write
this silent memorial of him. Should he, however, be still
abroad sometimes, perhaps, of fine summer evenings then,
kind reader, I thank you heartily, and trust, indeed, I may
have contributed somewhat to your pleasure and your profit ;
to your pleasure more, to your profit less. For while I would
not be vain enough to think to add to that learning and
wisdom in which you already abound, yet to your generous
mind I may hope I have offered that which is most pleasant
to it, namely, work done in an earnest belief that no facts are
small, no careful testimony trivial ; that the happiest pursuit
in human life is to seek out its truths, and to learn its ways ;
the greatest honour to have helped, be it ever so little, to
promote that science which ' should be a rich storehouse for
the glory of God and the relief of man's estate/

FINIS.

APPENDIX

CASES.

The Cases printed in the Appendix are intended
to have an illustrative value only. In them brevity
and certainty seemed to the author to be of the first
importance ; and it is hoped that the notes given
are sufficient to identify the conditions observed.
Few cases depending upon an autopsy are included
unless an autopsy was obtained. Hie author has to
regret that some of the most curious and interesting
cases in his ophthalmic collections must, for this
reason, be omitted. Many other cases are also
omitted which add nothing to our knowledge, or
which only add, without important difference, to
the illustrations here given.

APPENDIX.

CASES.

1. Epilepsy preceded by temporary blindness.

F. P , set. 1 7, was in health six months ago, when she was

seized by a fit, which has recurred sometimes twice or thrice a
week ; sometimes, however, not even once a week. Generally
they occur about noon, but sometimes later. She struggled a good
deal at first, but less so of late. At present, Sept. 14, 1868,
the first symptom is loss of sight, but this has only been the case
lately ; previously, she had no warning. There is complete dark-
ness and no coloured vision. In about two minutes she falls,
and thence recollects no more. She lies pretty quiet, and is
insensible from half an hour to an hour. Latterly she has
slept after the fits a good deal, and if so is much better. No
palsy or other permanent symptom. (The last fit was two
days ago.)

O. S. Disks seem perfectly healthy. Veins may be a trifle full.

If she does not sleep on recovery her sight remains weak for
perhaps half an hour, after which sight quite recovers, and is now
quite good.

2. Two cases of epilepsy, with notes of tlie state of the disks
after a paroxysm in each.

1 The following are notes of an ophthalmoscopic examination made
in two cases in which the patients complained of headache with a
little dimness of sight after a paroxysm of epilepsy. My object
was of course to learn somewhat as to the condition of the intra-

302 APPENDIX.

cranial circulation after an attack of epilepsy, and also to see the
state of the vessels of the retina and the nervous tissue (the optic
disk) supplied by them, in what, judging from the patients' state-
ment, would generally be called 'congestive headache.' For, as
the arteria centralis retinse may be almost considered as part of the
cerebral circulation, we shall no doubt learn, from studying its
varying ^conditions, something as to the condition of the other
branches of the internal carotid which supply the brain.

'In a case in which an epileptic complained of slight dimness
of sight and headache after an attack of epilepsy which she had had
the same day, the note is as follows :

' " She (a girl, set. 8, idiopathic epilepsy, and tongue-biter) had a
fit at 8 a.m. I examined by the ophthalmoscope at 10.30 a.m.,
without using atropine. I find the veins remarkably large and
dark, and the arteries also seem darker than normal. The disk is
hypersemic."

' In another case in which after a fit there was dimness of sight
and frontal headache, the veins appeared very large, and the optic
disk was reddened as if flecked with red. It was not uniformly
coloured, but somewhat like white bibulous paper slightly smeared
by red ink.'

Hughlings Jackson, <Med. Times and Gazette,' Oct. 3, 1863.

Also

'A patient, William T., set. 8, had been attending some time
under the care of my colleague, Dr. Brown-Sequard, for epilepsy.
One day the porter brought the boy (who had just been taken with
a fit) into my room in his arms. Unfortunately he did not at once
take him to the lamp, and, when everything was arranged for look-
ing, the convulsions had, I think, ceased ; but I was so much occu-
pied in finding the optic disk, that I noticed little else. The pupil,
however, was still very widely dilated, and I caught the optic disk
of one eye. It was whiter than normal, and the veins were large
and dark. I soon lost it, and then the pupil rapidly became so
small that I could not again illuminate the fundus. It is of course
of great moment to ascertain the exact stage of the paroxysm when
the disk is seen.' Ibid.

3. Epilepsy, hypercemia of disks.

Ann P , set. 18, was quite well three years ago, when she

was terribly frightened at a pic-nic. The same day she was l taken

CASES 35. 303

in a fit.' Since that time fits have returned, often with great
frequency. They are ordinary complete bilateral epileptic fits.

O. S. Examination. We examined the disks on one occasion
(April 29, 1879) in the out-patient consulting room during the
conclusion of a fit. Both disks were hypersemic, especially the
left disk. She was removed to Wakefield Asylum in a month
after she commenced attendance.

4. Epilepsy, retinal hypercemia, disks normal.
Miss H., a quiet, intelligent person of about 22, consulted the
author for epilepsy. I need not describe the case, as the points of
interest in it would lead us away from the present subject. The
fits were rather frequent, appearing once or twice at menstrual
periods. They were bilateral and rather severe. I do not think
there was any ' coarse disease' in the brain. On examination with
the mirror, within a few days of the attacks, the veins of the retina
were seen to be enormously dilated and somewhat tortuous. Pulsa-
tions even in the smaller branches were distinct. There was pro-
bably great fulness of the cerebral sinuses. The disks were but
little, if at all, hypersemic. Mr. Teale twice saw this state of the
vessels. The fulness of the retinal veins generally subsided in five
or six days, to return again with the epilepsy. I never saw her
immediately after a fit.

5. Convulsions, hypercemia papillce, death, autopsy.
Anne G., set. 22, was admitted into the General Infirmary under
the author on the 25th of February, 1868. She was a person of
doubtful character, her history unknown, and the fact of her present
seizure very difficult to obtain. It seemed, however, from the
evidence of a man to whom she was talking at the time, that she
had fallen in Briggate three days before in a state of convulsion.
She had recovered, but the fits had returned before admission. She
was in a semi-comatose state when brought in. Twenty-four hours
later she passed into a 'status epilepticus' (coma and convulsion)
which continued till death. Both sides were affected, and to the
same degree : the iris was strongly convulsed. I examined her eyes
repeatedly, and during long times, while both coma and convulsion
was going on, as my assistants and the nurses were able to hold her
tolerably still. I constantly found a fulness and slight tortuosity of
the retinal vessels, a full redness of the disk, including the central

304 APPENDIX.

connective tissue, dim cedematous margins, and a large number of
radiating vessels. I could see no neuro-retinal change during the
convulsions of the iris. The patient died in about twenty hours,
and, as I expected, we found only a marked fulness of the meningeal
veins and of the sinuses, rather numerous puncta, some excess of
serum in the ventricles, and a diminished consistency of the motor
ganglia.

6. Epilepsy, anaemia of disks and retinas.

Jane W , set. n, has suffered from bilateral 'genuine' epi-
lepsy for eighteen months. The fits have recurred at uncertain
but at somewhat short intervals. She was admitted into the Leeds
Infirmary on May i, 1868. I then found that the disks and
retinas were quite normal in all respects.

On July 23. Has had two fits this morning about four hours ago
and eight hours ago respectively. The retinal vessels are now fine
in both eyes, the disks are pale, and the left disk is much paler than
the right.

On subsequent examinations I noted that the disks were perfectly
normal, the vessels being full and well marked rather than fine,
and the disks reddish. The disks presented no difference of
colour.

7. Epileptiform seizures, aura from the thumb, attacks of
coloured vision,

(Under the care of Dr. Hughlings Jackson.)
1 Alice F., a married woman, set. 49, was admitted an out-patient,
under the care of Dr. Hughlings Jackson, on November 28, 1862.
Until about seven or eight months ago she had had good health,
and indeed looked still in fair health, and was very intelligent.
She had not menstruated for twelve months, and complained a
good deal of " sinking," of faintness, weakness, &c., symptoms
so common at the change of life. Until the attack to be described
she had had no definite ill-health, except a pain in the right arm, of
no very special character so far as could be ascertained.

1 Five weeks before she had a tingling sensation in the right thumb.
It began under the nail, and extended about as high as the styloid
process of the radius, and then " went to the face." The part of the
face first attacked was the upper lip on the right side ; next, the
whole of that side of the face, and the tongue also ; " it took her

CASES 68. 305

speech away for five minutes." She was not at all insensible. She
had great pain in the arm, but the leg was not affected in any way.
She had had about twenty of these attacks before admission.

1 It is interesting to note that, before any question of any kind
was asked, she said that catching the shuttle with the thumb and
finger, and even touching the thumb, would sometimes bring on
the fit. She gave a circumstantial account of this. She had also
attacks in which there was coloured vision, which were distinct
from the seizures just described. The first was about four days
before the seizure described above.

1 This patient took iodide of potassium. At her next visit she
was better, and had only had one attack. It was now ascertained
that she had had tapeworms three years ago.

1 December 19. She had had no fit, but "had had the colours
dreadful." It affected the right eye only, as she shut each eye
in turn, in order to ascertain. The coloured vision was attended
by pain in the right superciliary region. Both the pain and the
colour came and went suddenly, lasting each time about ten
minutes. She could see things in spite of this peculiarity, but
rather dimly. The colours were violet, white, and orange, and
seemed about three yards distant. At other times the sight was
good, and she had no pain. She had not at any time during these
attacks any vertigo or insensibility, but numbness of the right leg.
She had considerable pain still from the elbow to the fingers, but
this was constant. A dose of the oil of male fern was prescribed/
' Medical Times and Gazette,' June 6, 1863.

I have had two or three cases of this kind under my care, but
they do not differ importantly from this of Dr. Jackson.

8. Attacks of unconsciousness and of dizziness, transient
blindness.

Mr. G. C., set. 24, consulted the author in November 1868 for
attacks of sudden unconsciousness, which often caused him to fall.
Their duration was short. He had, however, suffered from almost
constant dizziness for nearly two years. When he has a ' full attack,*
he is blind for some minutes after his recovery. He is never con-
vulsed. He has lost flesh, and has a worn and anxious aspect.

0. S. Disks very hyperaemic, and edges hazy. The vessels are
full and dark. The left eye is the worse. I prescribed cod liver
oil and oxide of zinc.

306 APPENDIX.

He gradually improved until Jan. 7, 1869, when he became
again worse. Has had several attacks of unconsciousness, and
much dizziness.

0. S. On this day I find the right disk much the worse. The
left disk is hypersemic and indistinct, but the borders are to be
made out. The same treatment was continued, and the patient is
recovered. On the i4th of March the disks were quite natural in
appearance. All dizziness had disappeared.

9. Periodic nervous disturbance, hypercemia of disks.

Mrs. S. R., set. 23. Sixteen months ago had the first of a series
of attacks, which have recurred at varying intervals up to March
4, 1870, when she came under the author's care.

The attacks could not be called epileptic in name, however near
their affinity to epilepsy. Cramps and tremors seized the arm and
leg of one side or of the other, or arrested speech ; and when
speech was arrested the thorax was also fixed and breathing
stopped. Consciousness was never lost, though transient giddiness,
bewilderment, and loss of vision would occur ; sometimes she even
fell, but retained perfect remembrance of all that passed. No
marks of hysteria in symptoms or in constitution. Twice I saw
her just at the end of an attack which had lasted ten minutes in
the first instance and half-an-hour in the second instance. On both
occasions the fundus was very red and injected, and slight cedema
veiled the disks. In the intervals appearances normal.

10. Epilepsy, transient blindness.

' The total blindness preceding the epileptic paroxysm is a dif-
ferent thing ; and just as epilepsy is supposed to depend on con-
traction of the vessels of the brain, so the temporary amaurosis, in
these cases, probably depends on contraction of the blood-vessels of
the retinae an epilepsy of the retinse.

'I believe that the following is an instance of epilepsy of the
retinse. It seems clear that it was not merely failure of accom-
modation. One morning Julia W., a middle-aged woman, came to
me, saying that for five whole minutes she had been " blind." She
was at the time seated peeling potatoes. The blindness came on
suddenly and left suddenly. It was not total darkness, but " dark,"
which was the word she used herself in describing it. It was not
from failure of accommodation. I asked her to look through a

CASES 911. 307

very strong convex glass. It was not like that, she said. It was
not spots, nor specks, nor clouds, nor colours. When I saw her
a minute afterwards, she could read well with each eye, and the
fundus of each, as seen by the ophthalmoscope, was normal. She
had headache across the forehead, which continued the next day.
She said it felt "tight" across the forehead. She had no giddiness.
She was regular, but subject to dyspepsia.

'In cases in which loss of sight is followed by the epileptic
paroxysm, may we not say that the contraction of the blood-vessels
has begun in an outpost of the cerebral circulation (the retina being
supplied by branches of the same vessels as the brain, these vessels
being supplied by the same vasomotor nerves), and that, on exten-
sion to the other branches of the carotid, the " brain's blindness,"
loss of consciousness supervenes 1 ? In but one of the cases of
disease of the cerebellum which I have reported, was there any
note of temporary intermissions of sight. As a rule, the progress
is gradual, and the loss of sight permanent.'

Hughlings Jackson, * R. L. Oph. Hosp. Kep.' vol. iv. Part i.

11. Periodic nervous disturbances, transient dimness of vision,
eyes normal ?

Miss E. C., set. 29. Came under the author's care early in 1870.
Two years ago, when in ill health, became subject to attacks of dim-
ness of vision not amounting to actual blindness. The dimness
would, however, prevent her from distinguishing objects for about
half an hour ; it was accompanied by nausea, and often by vomiting.
As it passed off it left a severe darting pain through the temples.
These attacks troubled her almost daily for about two months, at
certain times of the day ; the least exertion being sufficient to
bring them on. Lying down always relieved them. Her health
has been feeble ever since, but no attacks recurred until a week
ago, when they reappeared just as before.

O. S. I examined her eyes on one occasion twelve hours after a
bad attack. The fundus seemed too red, and redder in one eye
than in the other ; but I could not feel at all sure that there was
abnormal injection.

These cases are very common, and the optic changes may be
significant of changes in encephalic vascularity.

X 2

308 APPENDIX.

12. Morning blindness, tapeworm, anaemia of disks.

Sarah H , admitted into the Leeds Dispensary, Oct. 28,

1867, set. 29. For twelve months has been subject to loss or
dimness of sight every morning on rising. It generally lasts for
about an hour and a half, and she is sometimes quite blind for that
time. She never has the attacks at any other time. Under treat-
ment she passed a great quantity of tapeworm, parts of which she
had passed before. No great difference in the sight, however, could
be noticed. She was then ordered a steel and tonic mixture, and
in about three weeks she entirely lost the disturbance of vision.

0. S. On admission is noted, the vessels small and the disks
' slightly atrophic in appearance, but probably only pallid.' When
discharged, the note of the disks is ' natural.'

13. Headache, vertigo, hypercemia papiUce.
M. W., set. 32. His sight had been imperfect for about a twelve-
month, and on that account he came to Mr. Teale's clinic, where the
author saw him. He complains of having suffered for some time
from constant vertigo, occipital headache, debility and depression.
Says that his habits are in every way steady, and he can give no
reasons for his illness. The heart is healthy and the urine normal.
Both disks are markedly hypersemic, and the veins full. There are
one or two twists or dilatations of vessels upon the disks, which,
unless highly magnified, resemble haemorrhages.

14. General ancemia, vertigo, fiery flashes, ancemia of disks
and retinas.

Mrs. M., a patient of Mr. Mann's, was first seen by the author on
April 13, 1868. She was a well-made and fairly nourished person,
who had lately been confined, and was partially suckling her baby.
Four years before, when in good health, had suffered a most painful
shock, followed at the time by great prostration. She had since
been profoundly anaemic, and was in this state at my visit. She
complained much of palpitation, vertigo, numbness, and prickling
in the limbs. The left arm and leg are chiefly affected, and we
feared that there was some weakness of these limbs *. Her most
painful symptom, however, was the recurrence of fiery flashes in
her eyes ; flashes which were so sudden and so bright as to alarm

1 Vide paper by the Author on Functional Hemiplegia, ' Br. Med. Journ.'
Oct. 1, 1870.

CASES 1216. 309

her very much, accustomed as she was to them. They recurred
like epileptic fits, at uncertain intervals, and generally at night.
During the last year and a half she had suffered also from night
blindness.

O. S. The back of the eyes are extremely anaemic, the vessels
small, and the disks resembling grey white paper. There was not
atrophy.

The result of treatment is interesting. Chalybeates and nervine
tonics having been long and well tried, we agreed to order bromide
of potassium in increasing doses, looking upon the flashings as
epileptic. Our hopes were justified ; the attacks were commanded
by the drug, and with the addition of cod oil and other supporting
treatment, she was so much better in eight or ten weeks that I took
my leave. It seems probable that there was no local disease of
the brain, although the suggestion of hemiplegia made us cautious
in our opinions. She still remains in good health.

15. Transient hemiplegia with aphasia) and blindness.

Mr. B., a sensitive, intelligent man, engaged in laborious under-
paid work, and suffering under needy circumstances and mental
anxiety, is seized at various intervals by fits of the following kind.
He becomes sick at the stomach, and dizzy ; then his sight fails,
leaving him altogether for about three minutes or less ; his right
arm and leg are enfeebled and very slightly convulsed, and speech
is lost.

Before the absolute loss of speech he uses inappropriate words
and feels much distressed at his inability to express himself. He
is likewise unable to write anything coherent or to the point. Con-
sciousness and intelligence to ingoing language are unaffected. The
attack passes off in about ten minutes with free vomiting. His
relief is then complete, and his memory unbroken. There seems
to be no organic disease, and he improved while under the author's
care with rest and tonic treatment.

O. S. The optic disks during the attacks are distinctly blanched,
and the vessels fine. They do not recover their full calibre for
twenty-four hours.

16. Periodic nervous disturbance, transient amaurosis,

fundus normal.

Mrs. A. M., set. 28. Admitted Leeds Infirmary, July 1870.
Much pulled down by death of several children and some mis-

310 APPENDIX.

carriages. Nothing further suggestive of syphilis. Six months
ago, when pregnant and feeble, but with no definite ailment, was
seized with hemiopia while cooking. Was unable to see the left
half of the pot, or of any object; then the tongue began to
tremble violently, and the lips also. Then the tongue seemed
to get too large for the mouth (anaesthesia T), and a numbness
ran down the left half of the face and the left arm. In two
hours sight returned, but the arm was 'numb' for twenty-four
hours. A second attack occurred four days ago at 9.30 p.m.
Suddenly objects became indistinct, then for a few minutes abso-
lute darkness, then again indistinct vision and sparks. During
the dark time the tongue ' again became much too large for her
mouth/ and her lips became very numb, while a numbness also
ran down to the end of the left fingers. On retiring to bed it
passed off, but she had a threatening next morning again.
O. S. The fundus of both eyes was quite normal
Vide paper by the author on Functional Hemiplegia of Women,
in 'Brit. Med. Jour.' Oct. i, 1870.

17. Attacks of unconsciousness, congestion and oedema of disks.

George C , set. 2 3, was admitted under my care in the Leeds

Infirmary on Nov. 27, 1868. He is liable to attacks of uncon-
sciousness, in which he falls to the ground. He has no struggling,
nor ever had any. This we learn from his friends. He soon comes
round, being seldom unconscious for more than a few seconds, but
he remains blind for some minutes. As he cannot enter the house,
we have no opportunity of seeing him in a fit, though they are
frequent. There is no heart disease.

O. S. Examination on Nov. 27, twenty-four hours after last
attack. Disks very hyperaemic, and edges hazy. Vessels full and
dark. Left disk rather the worse.

O. S. Examination, Jan. 7, six hours after attack. Disks as
before, except that the left disk is clearer, and the right disk worse,
being now worse than left.

0. S. Examination, Jan. 14. No attack since the last mentioned,
viz. Jan. 7. Disks both almost entirely cleared up.

Under tonic treatment with bromide of potassium the attacks
were postponed, and finally prevented. After the attacks the disks
were always congested, and cleared up in the intervals. On dis-
missal the disks had been normal for many weeks.

CASES 1720. 311

18. Aortic regurgitation, ancemia of disks.

Elisha W , set. 41, admitted under the author as out-patient

on March 20, 1869. Ill some months. Aortic obstruction, and re-
gurgitation in extreme degree. Liable to constant dizziness ; often
falls. At such times consciousness is seldom quite lost, but he
seems in a dream. Speech will depart also for many minutes.
Face and lips very bloodless.

O. S. Examination. Both disks white, equally affected, and like
atrophy of the first degree. Retinal vessels too fine. Has often
flashes of light in eyes, and mists. Field of vision complete.

Under steel and digitalis his general health much improved, and
the disks became a little warmer in colour; but he ceased to
attend after a few weeks, and before they had fully recovered their
natural tint. The evidences of disordered cerebral circulation also
diminished during the time of his attendance.

19. Chorea, optic signs, recovery.

'On September 6 I looked at the optic disks of Caroline B., a girl
ten years of age, and, as I was sitting down, I remarked to the
students that I had never found aDy striking changes in the eyes
of a choreal patient. I found them in this case. The changes
were most in the right eye. The optic disk was badly margined ;
the veins were large and very irregular (wavy) ; and the disk was
hypereemic. There were similar, but slighter, appearances in the
left eye. Now in this case, as in most cases of chorea, one side of
the body (the right) was affected. It was the side only affected.
There was, as I believe there always is in chorea, paralysis, and in
this case the paralysis was considerable. The child's talking was bad.
It was, when I saw her, slightly thick. I took her into the hospital
(thanks to the permission of my senior colleague, Dr. Davies).
The irregular movements degenerated into paralysis, so that the
arm was almost immoveable, and the changes in the optic disk
increased. However, she ultimately regained much power, and the
disks resumed nearly a normal appearance. She went to a Con-
valescent Institution in November. The arm was then nearly
restored.' Hughlings Jackson, ' R. O. Hosp. Rep.' v. p. 288.

20. Meningitis, atrophy of disks.

Esther E., set. 15 weeks, came under the author's care in October,
1868. Three months ago was seized by convulsions, and has had

312 APPENDIX.

many fits since then. Sometimes they consist only in a divergence of
both eyeballs to the left : sometimes all four limbs and the face and
neck are affected. There has been headache and vomiting through-
out, and these symptoms seem to recur periodically, like the convul-
sions, and to disappear as suddenly. The head is natural in size,
and there is no palsy, but the right side is generally more convulsed
than the left.

O. S. Examination. Both disks very white, borders irregular
and clouded, vessels not diminished. Child seems not to notice
anything. Under treatment by iodide and bromide of potassium,
with cod oil and steel wine, the child improved for some weeks ;
but at the end of the year she relapsed : fits, headache, and vomiting
severe, the fits generally setting in fifteen minutes after sleep had
commenced. The right arm and leg became palsied.

The child was an out-patient, but I learnt that she died on
April 8, 1869. I was unable to obtain an autopsy.

21. Meningitis, central softening, neuro-retinitis.

A. E. O'H , set. 4 years, has been ill six months with headache,

vomiting, and loss of flesh, A few slight fits have been noticed.
She had begun to talk very nicely, but by degrees had now quite
lost all speech, except a few baby words. (Loss of memory of lan-
guage "?). She was also losing power in all four limbs. Her hands
are almost constantly clasping her forehead, and she screams at
night. Muscles of orbit normal.

O. S. Examination on admission. Typical neuro-retinitis de-
scendens, in both eyes. Vessels about normal in diameter, except
where lost for more or less of their length in the reddish grey exu-
dation in and around the disks.

The mother brought the child for three or four weeks, and then
disappeared.

22. Phthisis, meningitis, amaurosis.

Harriette S., set. 7^, was admitted under the author's care into the
Leeds Infirmary on Feb. n, 1870. Mother is 'delicate,' and one
sister died of consumption. When one year old, began to lose flesh
and appetite, and to cough. Recovered to some extent under treat-
ment, but is liable to a return of the symptoms every spring and
fall. Six months ago was attacked with intense pain in head, con-
stant nausea, and attacks of vomiting. Five months ago convulsions

CASES 2124. 313

appeared, and lasted more or less for fourteen days. At this
time some failure of sight was noticed. After the fits she seemed
to improve, and has slowly become convalescent, though she re-
mains slightly hemiplegic of the right side, which side was chiefly
affected in the fits. She is now quite blind.

O. S. Disks bright white, and vessels atrophied. There are
marked signs of phthisis in the chest.

23. Meningitis, ophthalmic signs, recovery.

J. E. D., set. 9 months. Was admitted Leeds Infirmary, Oct. 25,
1867. Well till four months ago. Since that time has begun to
lose flesh, and to appear more heavy than natural. For one month
has been subject to occasional vomiting, and seems to have pain in
the head. These latter symptoms still continue.

O. S. There appears to be congestion, and slight infiltration of
the right disk. Left disk as right, but less in degree.

R. pot. iod. gr. i., ter. die. Nov. 21, pt. pot. iod. and ol. morrh.
jj. bis die. Under this treatment the child gradually improved,
and on Dec. 19 was ordered syr. fer. iod. n^. x., with ol. morrh. jj.
ter. die. With some occasional checks the improvement was on the
whole maintained.

O. S. On Jan. 16 it is noted, 'the left disk whiter than right
disk, which is red, and the vessels too distinct.'

The improvement steadily continued on the whole until March
12, 1868, when there was some return of the vomiting and oc-
casional screaming, so that one day the mother feared a fit was
coming on. The head is decidedly larger than it should be. There
is no strabismus. The treatment was continued and the bad
symptoms passed off"; so that on April 19 a very good report was
given. There had been no nausea, and no screaming or pain in
the head. The disks had not changed. In a few weeks after the
mother asked for a discharge, stating that the child was quite
well. It has since been lost sight of.

24. Hypercemia of disks, suspected meningitis.

Charles C , set. 1 1, admitted into the Leeds Dispensary on

Oct. 12, 1868. Is a pale, weakly-looking child, with a tumid nose
and lip. Has never been strong. Has only had one (sister) who
is dead. Patient suffered from cervical abscess at the age of 9,

314 APPENDIX.

beginning in suppurating glands. Now complains of severe pain
in the head of one month's duration. No vomiting. No fits.

O. S. The right optic disk is both pink and also a little filmy.
Edges indistinct. The vessels are too full, but the arteries may
yet be distinguished from the veins. Left disk as right, but more
marked.

25. Scrofulous eczema, headache, wakefulness, irritability,

meningitis (?), optic atrophy.

Master G. S., set. u, was brought to Mr. Teale on account of
his eyesight. His mother is ( delicate, and has a cough.' Patient
several years ago had extensive scrofulous eczema on the head and
behind the ears, and has always been weakly and liable to cough.
About fourteen months ago became weaker than usual, his appetite
fell, and he lost flesh seriously. He became also very wakeful.
For about eleven months his sight has been noticed to fail, and
during the same time, or longer, he has complained of violent head-
ache, which ' throws him into rages.' He has also become fanciful
and irritable, and at times he is a little delirious at nights. His
mind cannot be called unsound, but he is ' unable to bear any
schooling.' We found atrophy of both optic nerves, due no doubt
to descending neuritis.

26. Meningitis, atrophy of disks.

Samuel W , set. 3, was admitted an out-patient at Leeds under

the author's care in January, 1870. The family history is very un-
satisfactory ; the father is consumptive, and one child has died of
f brain fever.' Present patient never a thriving child, and of late has
become very irritable. It wakes up suddenly and yells, and seems to
have much headache. These attacks are often attended with vomit-
ing. One month ago became subject to 'ditherings' in limbs, so
that he falls down, or if in bed is generally convulsed. These
attacks last two or three minutes, and may occur several times
a day. This case might well have been called 'spurious hydro-
cephalus,' were it not for the

O. S. Examination. The child is so fretful, restless, and in-
tolerant of light, that one disk (the left) only can be seen. It is
distinctly atrophied, the retinal veins are dark and full, and there
are remains of old exudations around the margins of the disk,
signifying previous ischsemia papillae or neuro-retinitis.

CASES 2529. 315

27. Meningitis, recovery, amaurosis.

H. K , set. 10 months, was admitted into the Leeds Infirmary,

Sept, 30, 1870. Healthy until 'fever' and bronchitis six months
ago. The 'bronchitis' broke down her constitution and left her
very weak. Three months ago she began to have headache and
vomiting. She also screamed out frequently with pain in the
head, and became very irritable in temper. Latterly she had
several attacks of convulsious. She then slowly recovered until a
week ago, when the parents first became aware that the child was
blind.

O. S. There is convergent strabismus of the right eye which
was not congenital, and both disks show that state of atrophy with
ragged edges and full retinal vessels which tells of past optic
neuritis.

28. Meningitis, retinal hypercemia.

Not to rely on my own cases more than necessary, I quote the
following case of meningitis from some related by Dr. E. Long Fox,
of Clifton ; in this case only is there any record of opththalmoscopic
examination.

' Case XXVI. Mary E., set. 23, single, acute headache, photo-
phobia, tinnitus aurium. Vomiting at outset. Urine albuminous.
No convulsion. Strabismus (slight) on 5th day, death from in-
creasing coma on 7th day.

* 0. S. Papillae dull white on 3rd day with large vessels radiating
from them. 5th day and 6th day, papillae darker, and the vessels
more numerous and larger than in health.

' Autopsy. Whole of arachnoid at base, and especially in fissures
of Sylvius, thickened and granular, &c., &c.'

' St. Geo. Hosp. Reports/ iv. p. 82.

20. Suspected tubercular meningitis, ophthalmoscopic signs

negative, recovery.
(Royal Hospital for Diseases of the Chest, City Road, under the

care of DE. SANSOM.)

' Walter M., aet. 1 1, was admitted as an out-patient on November
1 6, 1867. He complained of shortness of breath, pain in the
chest, and severe headache. Two years before his admission, whilst
at school, he complained of dulness of sight. For twelve months^

316 APPENDIX.

he has been losing flesh. He has suffered from headaches, which
latterly have increased in severity, and they now give rise to crying
and fretfulness, and the height of these paroxysms is described
as " dreadful." The hereditary tendencies are as follow : father
suffers from chronic bronchitis ; mother has frequent headaches, so
also have the brothers and sisters ; one sister suffers from rickets
and general debility. The following describes his condition : thin ;
small flabby muscles ; pale ; head large and flattened ; teeth much
notched ; high arch of palate ; slightly deficient resonance in left
apex of chest ; here dry riles, and respiration harsher than in right.
Ordered counter-irritation to the chest by turpentine liniment ; one
grain of iodide of potassium and half-an-ounce of infusion of bark
three times a day. No improvement followed ; on the contrary,
the headache became frightfully intense ; it occurred every after-
noon at two o'clock, and was accompanied by screaming.

' Considering the emaciation and the physical signs suspicious of
an early stage of pulmonary tubercle, Dr. Sansom was led to fear
that the violent headache might be due to incipient intra-cranial
tubercle. To investigate this point he made an ophthalmoscopic
examination. He found that the fundus of each eye was rather
paler than usual ; the optic entrances were of their normal colour,
and the vessels were smalL In each eye the appearances were per-
fectly similar. This examination tended to negative the idea of
tubercle in the meninges ; for it would be probable in such case to
discover hypersemia instead of anaemia, and the perfect similarity
of each would not obtain.

1 The following treatment was adopted : cantharides blister be-
hind each ear ; ten grains of bromide of potassium, afterwards in-
creased to fifteen grains, three times a day ; cod-liver oil twice a
day.

'The boy gradually improved, and on January 18 the note
states, " He is mending very greatly, is livelier, and the pain in his
head has greatly disappeared." The pulv. sodse c. ferro of the hos-
pital Pharmacopoeia was added to the treatment.'

< Lancet,' Feb. i, 1868.

30. Tubercular meningitis, no change in the optic disks, mischief
found to be confined to the posterior regions of the encephalon.

, a little child under the care of Mr. Carter of Stroud,

suffered from all the symptoms of tubercular meningitis, followed

CASES 30, 31. 317

by death. Mr. Carter forwarded to the author the following notes
of the autopsy.

' Stroud, March 20, 1868.

' After the death of my little patient the other day, I opened his
head, and found the pia mater of the surface of the hemispheres
intensely congested, the sinuses of the dura mater gorged with
blood, the convolutions somewhat flattened, and the quantity
of cerebro-spinal fluid increased. There was no increase of fluid
in the ventricles, no trace of congestion of the optic nerves,
and no mischief at all about the anterior part of the base of the
brain. There was tubercular deposit and inflammatory adhesion,
small in quantity and slight in degree, about the cerebellar pia
mater, especially between its hemispheres. I could not open the
orbits and follow down the sheaths of the optic nerves ; but the
autopsy showed that there could have been no change in the eyes
beyond some impediment to the return of the blood ; and of this I
could see no sign, long after all doubt about the nature of the case
had ceased/

81. Tuberculosis, meningitis, amcwrosis, death.

'A smith, set. 45, enjoyed good health up to set. 32. Comes of
a tuberculous stock ; became bronchitic, lost his appetite, and at 40
had to leave his occupation. At length, in addition to extensive
lung mischief, symptoms of tubercular meningitis set in. Head-
ache and loss of memory, &c. had existed two years, and loss
of vision began six months ago, and ended in blindness in four
months and a half.

' O. S. Exam. Irids contracted and immovable. Media clear.
Both disks swollen, steep, muddy, and remarkably red. Neither
scleral nor choroidal edge visible, the surrounding retina dull, the
arteries thin and the veins abnormally wide, and thrown into
strong curves.' (Ischsemia Papillse. T. C. A.)

Pagenstecher and Samisch, ' Augenheilanstalt zu Wiesbaden,' Part
i. 1861, pp. 53, 54.

I presume an autopsy was made, as the case is recorded as menin-
gitis, but no details are given. Such a conclusion of pulmonary
tuberculosis has often occurred in my practice. T. C. A.

318 APPENDIX.

32. Meningitis diagnosed by the optic signs, autopsy.

Madame X., set. 28, admitted into -the Hotel Dieu, March 31, 1866.
Complained of violent supra-orbital pains, chiefly at night. No
fever. Pulse slow and regular. No vomiting, indigestion or con-
stipation. Intelligence perfect and no suspicion of meningitis
arose. M. Peter failed to relieve her by antisyphilitic means.
Galezowski examined the eyes.

0. S. Margin of disks concealed by infiltration ; a small haemor-
rhage at the upper and outer part of the right disk, some white
streaks along the vessels. At a later period a haemorrhage appeared'
in the retina of same eye and more white exudations. Diagnosis,
meningitis of the base.

The patient's state had become aggravated, and death occurred
on April the 28th.

Autopsy. No dropsy of the ventricles. Meningitis at the base
of the encephalon. Many granulations. Miliary granulations
found also in the lungs. Microscopic examination of the optic
nerves. Their fibres were unchanged, but the sheaths were in-
filtrated, softened, and contained pus cells.

Galezowski, 'Etude Ophth. sur les maladies cerebrales,' pp. 136,
137-

33. Meningitis, retinal hypercemia, death.

A. B., set. 25, under Dr. Reynolds in University College Hos-
pital. Admitted November 10, 1869. Had headache, fever, rest-
lessness, twitchings of face and upper limbs. Died comatose on the
third day after admission.

O. S. On admission pupils slightly dilated and acting well to
light. Hypersemia of both retinse, more marked in the left.

Autopsy by Dr. Bastian. ' Surface of arachnoid dry and sticky.
Convolutions of vertex notably flattened. Some small yellowish
white patches of lymph here and there along the vessels ; very
slight, however, on vertex, but more marked on vessels emerging
from each Sylvian fissure. Base of brain lined by a thick layer of
greenish yellow lymph, from optic commissure back over pons and
whole of medulla oblongata, laterally to adjacent surface of cere-
bellum. No obvious tubercular granulations on vessels. Ventricles
distended notably, and corpus callosum diffluent. White substance
of hemispheres softer than natural.'

' Medical Times and Gazette,' June 18, 1870.

CASES 3236. 319

34. Tubercular meningitis, vomiting, ischcemia of disks,

dropsy of nerve sheaths.

A lad, set. 16, was under Manz with headache, vomiting, &c.
He found the disks swollen and hyperseniic. The patient was un-
conscious, and died in four days. The pia mater at the base, espe-
cially about the chiasma, was infiltrated and covered with layers of
fibrin. There was miliary tuberculosis here and elsewhere. The
optic nerves were from twice to thrice their natural size, owing to
distension of their sheaths with serous exudation. The nerves
themselves were normal up to the sclerotic. The disks were swollen
and muddy.

The retina and choroid were normal.

Manz, 'Zehend. Klin. Monatsbl.' iii. 1865.

35. Meningitis (?), optic atrophy.

No. 12. Charlotte T., seen Oct. i, 1866, set. 7. Fair complexion,
red hair, large head, thick alse nasi. Could walk well, was cheerful
but nervous. Illness began Jan. i, 1866. Pains in limbs, sickness,
convulsions, loss of speech for an hour or two at a time when re-
covering from the convulsions, delirium at times, complete paralysis
of legs, and for a long while inability to bend her back, stiffness
and pain in neck. In five weeks began to get about again, and it
was then noticed that the eyes were crossed. She was supposed to
see well. Her hair all came off. In a week or ten days the left
eye was found to be failing. In a month the right eye failed also.

Pupils large, sluggish.

O. S. White disks (dirty white) abruptly margined. No disease
at yellow spot, The large veins and arteries somewhat diminished
in size.

Hutchinson, ' Royal Lond. Oph. Hosp. Reports,' vol. v. Part iv.
P- SIS-

36. Meningitis (?), optic neuritis.

'No. 8. Wm. Fisher, seen May 28, 1866, set. 13. He could
walk quite well. History of fits and "dreadful pain in his head"
in February. Was admitted into St. Thomas' Hospital (Dr. Bris-
towe) in March. At this time mother said the right eye looked
larger than the other. In the hospital he got much worse, and was
expected to die. When discharged he could not walk ; he did not

320 APPENDIX.

seem to have any use in his legs. Both pupils were motionless,
the right being twice the size of the left.

' 0. S. In both the optic disks were dirty and fluffy, the margins
being concealed ; the arteria centralis much diminished in size, and
the vessels on the disk being concealed in part by the deposit of
lymph. In both the appearances of neuritis were passing off, but
the right was further advanced in atrophy than the left.'

Hutchinson, loc. cit.

37. Meningitis, optic signs.

The following case was placed in the author's hands by his friend
Mr. Seaton, of Leeds :

1 Butler, set. 3^, delicate, had tender eyes, and could not walk
till set. 2. Dec. 14, 1870, was seized with a fit, with subsequent
drowsiness. 1 5th. Still drowsy and apathetic, but conscious when
spoken to. i6th. Same state. No heat of head. ifth. More
unconsciousness. Pupils dilated and inactive.

* O. S. Brilliant choroidal glow j optic disks in both eyes very
red, so as not to be readily distinguishable. Retinal vessels normal
in course and calibre, but they had lost their defined outline, and
had a " furry " appearance. ((Edema ? T. C. A.) Near left disk a
cloudy patch on the retina.

1 During the next two days the head became hot, the eyes in-
jected, and the child died with strabismus and coma.'

38. Traumatic meningitis in a horse, optic atrophy.
Mr. Fearnly, a very intelligent veterinary surgeon, in Leeds, has
made frequent use of the ophthalmoscope in treating animals. A
horse was brought to him, said to be suffering from lameness, but
he was able to assure himself that the animal was staggering from
disease of the encephalon. He examined the eyes, and was sur-
prised to find the nerve entrance quite white, and all the vessels
'as fine as wires.' The animal he then found had had three
epileptic fits. These were repeated, and death occurred in a few
days. On opening the head he found injury to the occipital bone,
and traumatic meningitis all along the base, the membranes seeming
to be ulcerated in many places.

Communicated by Mr. Fearnly to the author.

CASES 3740. 321

39. Tuberculosis, rheumatism, meningitis (1), convulsions,

retinitis.

C. W., set. 26, complains of failing sight. Both in herself and
in her family there is a marked history of tuberculosis. Two years
ago she had rheumatic fever, and had at that time much pain in the
head, which has continued ever since. Seven months ago had a
fit, slightly affecting the right side ; has had many since, often six
or seven in a week. No heart mischief. Dulness at apices of both

lULgS.

O. S. Feb. 4, 1868 : Both disks were found slightly raised, and very
pink, scarcely to be distinguished from the retinas. Reads 10 Jag.
with right eye, 16 Jag. with left eye. March 2 : Position of right
disk known only by convergence of vessels. Retina very hypersemic,
and silvery films are forming upon it. Left eye as before.

This girl was probably suffering from meningitis, tubercular or
rheumatic. I have notes of two other cases, in which there was
reason to suppose that meningitis had complicated rheumatism,
and in which there were remains of optic neuritis.

C. W. ceased to attend upon the author and Mr. Oglesby, and has
been lost sight of.

40. Eruptive fever, meningitis, idiocy, old mischief in and

about the optic disks.

M. J. A., set. 4. Was quite well and intelligent up to fifteen
months ago, when she had an eruptive fever (scarletina 1). Be-
fore convalescence was secure she was seized with headache, vomit-
ing, and convulsions. After many weeks these symptoms slowly
subsided, but have not yet disappeared. At this time her mind
was found to be much impaired also.

O. S. The disks are dirty white and blotchy. Traces of old
effusions about their margins, and along the course of some of the
vessels. A few veins in both eyes are very dark and tortuous.
Sight is thought ' not to be very good.' Under iodide of iron and
cod oil the child improved in general health, but still vomiting and
slight convulsions reappeared from time to time. Her mind, how-
ever, deteriorated still more. She quite ' lost her head,' and be-
came very mischievous. She remained under the author's care about
six months, the only change in the disks being that the large veins
slowly diminished in size. The vomiting and fits seemed wholly

322 APPENDIX.

to disappear, but in all probability the child would find her way
into an asylum.

41. Scarlet fever, meningitis, sudden death.

In January, 1870, the author was asked by Mr. Hopkins to see a
little child, set. 4 years, who had been attacked, three weeks before,
with scarlet fever. His recovery had been fair and without albumi-
nuria, but there was some swelling tending to suppuration at each
angle of the jaw, and during the last week head symptoms had
crept on. I found a 'strumous'- looking child with large head,
almost immovable pupils, and fretful, hypersesthetic manner. I
learned that he had become drowsy and wildly delirious at night,
that he had intense pain and heat in his head, nausea and occa-
sional vomiting, and once or twice transient strabismus. The sub-
maxillary swellings were opened by Mr. Hopkins a^d some
grumous matter let out. There was no serious mischief in these
parts. The continued use of mild purgatives had acted very
beneficially upon the head symptoms.

O. S. Veins of both retinas very full and dark, and slight effu-
sion obscuring the disks.

I hoped this might only signify encephalic congestion, and this
hope seemed to be strengthened by the apparent success of the
purgations. We ordered quinine and iodide of potassium. The
child seemed to rally, again relapsed, rallied again, but finally had
another severe relapse, in which he died, after the manner of that
deceitful disease, meningitis.

42. Scarlet fever, meningitis, hyper cemia of one disk.

Rebecca R , set. 10, was admitted under the author in August,

1867, and was a long time under notice. A few months before,
when in excellent health, she had scarlet fever rather severely,
and had a discharge from the right ear. On admission, this ear,
as tested by watch, was deaf, the watch could scarcely be heard at
one and a half inch, which in a few weeks she was able to hear at
eight inches. There were many symptoms of local meningitis at
the base, such as headache, sickness, strabismus (external) of right
eye, <fcc., which I need not detail at length.

O. S. Right disk very pink, vessels full, edges indistinct. Left
disk normal, or nearly so.

Reads No. 6 (Jager) only with right eye ; reads No. 2 with left.

CASES 4143. 323

This child remained a long time under my care, and under the
use of iodide of iron and cod oil, with the occasional use of chalk
and mercury, she completely recovered. Her mental faculties, pre-
viously much weakened, were restored ; her right disk cleared, and
the right ear became sensitive to sound. She was threatened, how-
ever, with pulmonary symptoms when she was discharged on the
family removing elsewhere.

43. Scarlet fever, otorrhcea, meningitis.

G. H., set. n. Scarlet fever at set. 2, followed by discharge
from ears, which still (July 2, 1867) continues. Eight years ago
had * brain fever,' said by the doctor to be due to the otorrhsea. He
is decidedly deaf. At present suffers from symptoms of menin-
gitis ; is at times strange and almost maniacal in manner ; has
attacks of intense headache ; nausea ; occasional vomiting ; con-
vulsive attacks ; intolerance of light ; transient debility of limbs ;
inability for mental work. These symptoms vary a good deal in
frequency and intensity ; sometimes is free for several weeks, when
he will suddenly run into the house with a violent access of headache.
Is always best when ears are discharging freely; they discharge
most freely when the boy is warm. The whole neighbourhood
of the left ear is puffy and tender, especially behind the pinna. In
both disks is well-marked ischsemia. The bright cedematous disks
stand out steeply, and the vessels ride over them, and the veins are
full and dark.

Sept. 1 7. Has been treated with iodide of potassium, cod liver oil,
and small doses of corrosive sublimate. Is better. Has had one fit
with unconsciousness. Has still morning nausea. The disks have
receded, leaving a more plain surface ; their edges are undistin-
guishable ; the vessels are large and dark, and there is still some
osdema.

Oct. 15. Much as before. Disks flatter and less cedematous.

Dec. 24. On the whole much better. Disks as last report.
Yesterday, however, had intense pain in head ; screamed and rolled
on the floor. Has lately been taking syrup of iodide of iron and
cod liver oil.

Dec. 31, 1869. Has recovered a good deal from his head symp-
toms, and his ears are much less troublesome. There is now but
little discharge. The edges of the right disk have cleared all
round, except quite at the inner edge. The left disk is indistin-

Y 2

324 APPENDIX.

guishable, but the vessels are not distended. Sight in both eyes
good, and always has been. Has a cough, and there are evidences
of degeneration at both apices.

44. Erysipelas, delirium, amaurosis.

* On Sept. 18, 1862, a girl named Cultur, set. 14, came to the
Clinique of M. Desmarres. Her sight had been weak for three
months. Three months ago she suffered from erysipelas of the
head, with violent delirium ; and on recovery her vision was found
to be defective, and she suffered from constant pains in the frontal
region.

' 0. S. Atrophy of both disks was found.'

Bouchut, loc. cit. p. 246,

45. Optic neuritis, or ischcemia papillae, in pycemia.

(Letter from DK. CLIFFORD ALLBUTT to the Editor of the
< Medical Times and Gazette.')

' Sin, In your journal of last week, Dr. Hughlings Jackson
writes to ask whether other ophthalmoscopic observers agree with
him in reporting changes of the optic disk in pyaemia. He appears
from his expression " swollen disks " to have noticed the condition
I have ventured to call ischsemia papillae . I entirely agree with
him as to the occurrence of ischsemia papillae or of optic neuritis in
pyaemia, as in other diseases of like character where meningitis may
occur. I have little hesitation in saying that meningitis was pre-
sent in the cases Dr. Jackson records. He himself observes that
the state of the disks was like that which he had observed in a
case of tubercular meningitis, and in a case of syphilitic disease of
the base, which again was probably more or less meningitic in
character.

'In support of the co-existence of optic neuritis or ischaemia
papillae with pyaemia, and in support of the proposition that men-
ingitis is the immediate cause of these states, I will bring forward
a case which came recently under my notice, and for which I am
indebted to Dr. Crichton Browne, of the Wakefield Asylum, as I
am indebted to his great and untiring courtesy for very much more
of my pathological and other experience. A patient recently died
in the Wakefield Asylum from pyaemia, and Dr. Browne, who was
present at the autopsy, was kind enough to note particularly for

CASES 4447. 325

me the state of the optic nerves. Scattered pygemic abscesses were
found in some numbers in both lungs, a number of minute ab-
scesses in the kidneys, blood-stains upon the heart and valves, and
other clear evidences of pysemic blood-poisoning. There had been
much delirium before death, and very marked meningitis was found
about the base of the brain. The optic nerves also were found to
be very vascular and diminished in consistency, the chiasma and
branches were affected up to the eye, and backwards the same
changes were found in the tracts and up to the corpora quadri-
gemina/ ' Medical Times and Gazette/ June 27, 1868.

46. Enteric fever, meningitis, paralysis of cranial nerves.

James O'B., set. 7, admitted under the author's care into the
Leeds Infirmary on April 15, 1870. Had enteric fever very
severely the October preceding. Had severe headache, vomiting,
and intolerance of light, with slight convulsions during the fourth
week. On convalescence, was noticed to have external strabismus
of the right eye.

O. S. Now some deficiency of vision, and commencing atrophy of
both optic disks ; ptosis of both eyelids, in right eye almost com-
plete ; and external strabismus of right eye.

N.B. I have five cases of optic atrophy following continued fever
with severe head symptoms, but they do not present any important
differences from the foregoing. T. C. A.

47. Hydrocephalus, ischcemia of disks, and subsequent slight
atrophy.

W M , set. 15 months, admitted out-patient under the

author on January 17, 1868. Always delicate, but ' ailed nothing'
till two months ago, when he began to be fretful and sometimes
complained of headache. There was no night screaming, vomiting,
or strabismus. The head has been slowly enlarging since, and is
now decidedly but not greatly swollen. The mother is delicate and
has a cough.

0. S. Examination. Both disks prominent and vascular, but
tolerably transparent. Edges invisible, but no exudation extending
upon the retina or concealing much of the vessels. (Vide ' Descrip-
tion of Ischsemia papillae.')

(Stauungs papilla, noted on card). Under long and careful

326 APPENDIX.

treatment with cod oil and the iodides, the child improved very
much, and the head lessened by two inches in circumference.

O. S. Examination, March 12. The disks have gradually sub-
sided, but are whitening. The sight seems certainly very defective.

O. S. Examination, July 1 1. Disks greyish white, edges blurred.
Sight much improved. Discharged ' cured.'

48. Hydrocephalus, injured disks.

H. T., set. 8, admitted under the author into the Leeds Infirmary
Jan. 12, 1868. His head has been slowly enlarging for five or
six years. At present decided hydrocephalus, but not extreme.

O. S. Optic disks smudgy, as if there had been extensive effusion
in and near them some time ago. The evidence of interference is
very decided, and the disks look grey, but the child is not blind.
The father however, when questioned, says the child's sight is cer-
tainly somewhat defective.

49. Hydrocephalus, destruction of disks and retinas.

A. G , set. 5 months, admitted into the Leeds Dispensary

on March 31, 1868. Has one brother, aged 2\ years, who is quite
healthy. None dead. Mother has a cough and ' is delicate.'
Present child born healthy. At two months old it ' began to roll
its eyes about,' and the head began to enlarge. There has been no
great disturbance of general health. The vision is supposed to be
very defective or nearly absent.

O. S. Both retinas show well-marked patches of exudation,
some brown and dotted with pigment, others white. Disks both
quite white. The vessels do not seem much changed, but the
examination is difficult.

50. Hydrocephalus, atrophy of disk.

James K , set. i year, admitted into the Leeds Dispensary

on July 27, 1868. Two or three months ago was noticed to be
much ailing, to be restless and sleepless, and the head began
evidently to enlarge. This has been especially noticed during
the last month. It is now obviously of too great bulk. The
child is very irritable, but there is no marked vomiting. The
brother died of 'water in the head and lung affection/ and 'this
is getting like him.' Both children seemed healthy when born.
There are older children living, reported healthy.

CASES 4853. 327

O. S. Left disk only seen, as the child was very ' fractious ; '
this disk was white and blurred at the edges. The retinal vessels
were large, but not very greatly distended.

51. Hydrocephalus, atrophy of disks.

B. S , set. ii months. Admitted into the Leeds Dispensary

on Sept. 7, 1868. The head has been noticed to be decidedly
growing too large for six or eight weeks. Ten days ago occasional
vomiting set in, occurring about once a day, and ' purposeless.' The
legs seem weaker than natural.

O. S. Both disks are whiter than natural, probably atrophic. The
retinal vessels are full, and seemed to point to a past stage of con-
gestion.

This patient did not attend again.

52. Hydrocephalus, commencing change in disks and

retinal vessels.

, set. i year and 9 months, was brought to the
author on Oct. 26, 1868, with symptoms of hydrocephalus. The
disease had come on somewhat rapidly, the child's head having
become evidently large within three or four weeks. Occasional
vomiting for one month. Nutrition somewhat impaired. The head
is not greatly increased in size, but is decidedly larger than normal,
and the forehead is a little bulged.

O. S. In both eyes there is some vascular change. The retinal
vessels are a little too large and some of them are tortuous. The
disks are very pink, and the small vessels nearing the disks rise
a little over an elevation on one side, showing a slight degree of
ischsemia papillae in both.

53. Blow on head, concussion, left hemiplegia, paralysis of

orbital muscles, optic neuritis, death, meningitis.
A little boy, supposed to have fallen down stairs. When seen
by Mr. Hutchinson was wholly insensible; left limbs weak; of right
eye the pupil is dilated, the ocular muscles all paralysed, the con-
junctiva congested, and there is neuritis of the disk. The head had
been injured three weeks before marked symptoms of cerebral
disease set in, though during all that interval he had been heavy and
stupid. Then came on shivering, sickness, and constipation. He

328 APPENDIX.

died a few days after Mr. Hutchinson saw him. The family
attendant, Mr. Owen of Leatherhead, made the autopsy, and found
that there was, as had been diagnosed, meningitis at the base on
the right side.

Hutchinson, 'R L. 0. H. Reports,' vol. v. p. 108.

54. Blow on head with cricket-ball, subsequent head symptoms,
meningitis (V), death.

On the 3oth of August, 1869, the author was requested by Dr.
Burnie of Bradford to see Master C., who was suffering from obscure
head symptoms. I found a case which much resembled those which
often follow railway and like accidents. The boy, who was na-
turally healthy and strong, had been struck on the head, when
at school, by a cricket-ball. This occurred during the spring half-
year, about the beginning of May. He was felled to the ground
and remained there, stunned ; he was lifted up and taken into the
house, when he seemed to recover as from an ordinary concussion.
He seemed well for five or six weeks, when he began to droop.
He was irritable, unable to apply himself to work, sleepless and
moody. These symptoms got worse, and he was brought home.
In addition to the above symptoms, he now complained of headache
in the occipital region (where he was struck), and of nausea with
occasional vomiting. When I saw him, his general health, strength,
and nutrition had failed so much that he was almost confined to
bed, and could scarcely read the lightest books. He had never had
any strabismus or convulsion, but had once or twice suffered from
startings in the body and limbs.

O. S. The pupils did not act well, but were equal. The veins of
both retinas were very full, and a good deal of serous effusion in
the inner half of both disks. Both disks were veiled with a film
of serosity.

I explained to the father that ophthalmoscopic signs were yet
too little understood to be of certain value, but that I believed
there was serious head mischief. This the event proved, for the
boy died some weeks later with symptoms of compression. No
post-mortem could be obtained.

55. Two cases of concussion with amaurosis.
'(1) P. A., a locksmith, set. 32, fell from a ladder upon his head
&ix weeks ago. Was unconscious for twenty-four hours. Amau-

CASES 5457. 329

rosis of the left eye then set in, with headache, but no other palsy
appeared. It would seem that the mischief lay between the eye
and the chiasma.

' (2) Miss E., set. 1 8, fell down three steps three weeks ago, and
was taken up unconscious, and remained for twenty-four hours.
Then came on severe headache and spine-ache with paralytic symp-
toms on the right side. The sight and mental faculties (memory, &c.)
also declined. On admission seems stupid, and takes no notice.
Palsy of movement on right side.

1 0. S. Both disks turning white.

' No farther account is given/

Pagenstecher, ' Augenheilanstalt zu Wiesbaden,' Part iii. 1866,
pp. 77, 78.

56. Concussion, amaurosis, meningitis ?

' A peasant, set. 55, fell fifteen feet on to a barn floor; he was
brought home and put to bed unconscious. This was six years ago.
He recovered slowly and incompletely; the head had suffered
chiefly, and a depression remained. He had feverish attacks,
with vomiting, dulness, and incapacity for work. His sight also
failed, chiefly on the right side. When seen there was white
atrophy of the right eye, and loss of the inner and upper quad-
rant of the field of vision. The left eye seemed normal. There
was palsy also of the right rectus internus. At the angle formed
by the sagittal with the lambdoid suture on the right side of the
skull was a depression the size of a gold piece, and one and a
half lines in depth.'

The patient seems to have obtained some relief from treatment,
and to have returned home, which suggests that the internal
mischief was rather chronic meningitis than sclerosis.' (T. C. A.)

Pagenstecher and Samisch, 'Augenheilanstalt zu Wiesbaden,' Part
i. p. 67.

57. Blow on head, tumour of right posterior lobe, amblyopia.

In the last year of the American war a man, set. 23, was struck
upon the head with a splinter of a shell, which stunned him.

Mental defects, restlessness, severe attacks of headache, vomiting,
and latterly strabismus, were the chief symptoms which followed.
In addition to these the pupils were dilated, and there was ambly-
opia. After death a cheesy mass was found in the upper part of

330 APPENDIX.

the right posterior lobe, which was glued to the membranes and to
the calvaria. The seat of this mass corresponded to the place of
the blow. ^

Lomax, 'Philad. Med. and Surg. Keporter,' July 31, 1869.

58. Blow on head, amaurosis, autopsy, sclerosis of brain.

1 A young lady, set. 15, received a tap rather than a blow on
the right side of the head. It gave her at the moment rather
severe pain, and for thirty years she continued subject to headaches,
commencing in the part struck. She then, though naturally
very lively, began to grow heavy, and sometimes stupid and
sleepy. For the last year and a half of her life it was difficult to
keep her awake, but when she was awake, though it was but
for half an hour, she displayed all her natural brilliancy of con-
versation. She became completely comatose, and died convulsed.
Her vision had become very much, though very gradually, im-
paired.

'Autopsy. Bone, at part struck, of very dark colour over a space
equal to a crown piece ; that part of the parietal bone being in fact
transparent, and almost absorbed. Its dark colour was derived
from the hemisphere under it, which was black, and the dura mater
was absorbed. The portion of brain under the injury was in-
durated and scirrhous, and this change had taken place through
the whole of the middle lobe of the cerebrum. The optic nerves
were compressed and as flat as tape.'

Quoted by Mackenzie, from Howship's ' Surgery.'

59. Blow on head, amaurosis, autopsy, sclerosis of brain.

1 A young gentleman, set. 1 2, was struck on the right side of the
head, and an obstinate wound resulted, and remained for six years.
It then healed, and soon he perceived that his sight was failing.
He then became epileptic and blind. He was trephined, without
discovering disease of scalp, skull, or membranes ; the pupil now
became sensitive, apparently owing to the escape of some blood
and serum, but blindness remained. Fever now came on, and he
died soon after.

' Autopsy. Cranium healthy ; so was the dura mater. . Below the
place of the operation the pia mater was found to have evidently
suffered from chronic inflammation over a circumscribed space. On
cutting into the brain it was found indurated to a considerable

CASES 5861. 331

degree, and this induration had extended itself to the whole of the
middle lobe of the cerebrum, commencing upon the surface of the
hemisphere, and passing through the brain down to the basis of the
cranium.' Quoted by Mackenzie, from Howship's ' Surgery.'

60. Blow on head, aphasia, autopsy, sclerosis of brain.

John W , of Drighlington, was struck down in a fight, and

fell with the left temple upon an iron plate. He was stunned and
sick, but was able to walk home (about half a mile). From the
moment of the fall he was dumb, and never for the rest of his life
could say the commonest sentence. He was otherwise bright and
intelligent, and pursued his calling as a cap-hawker. He was under
the author's observation for some time, but nothing wrong was to be
found save the scar on the temple and the aphasia. He could only
say three or four words, and these he used quite irrelevantly. About
nine months after the accident his sight failed, and the disks atro-
phied, but he never became blind. He died about two years after
the fall, having become epileptic about nine months before death,
and hemiplegic on the right side about three months before death.
Dr. Sykes of Drighlington was so kind as to make great efforts
to get an autopsy, and he succeeded. We found no disease of
bone or parietal dura mater. Over the upper part of the left
anterior lobe there were marks of old meningitis with thickening
and adhesion, and the whole of the lobe, including Broca's con-
volution, were sclerosed, and presented the miscroscopical characters
of that change. The left striate body was much softened. The
optic nerves were decidedly atrophied, but not compressed.

61. Fracture of base of skull, retinal changes.

1 The patient was a man who had a blow upon the head, by which
the base of the skull was fractured. Jacobi examined the eyes
several times during life, and also after death. He found on the
eleventh day after the injury large yellowish white patches with
small extra vasions of blood, and after death he noted conglomera-
tions of granule masses in the middle layers of the same parts of
the retina/ Jacobi, A. f. O. xiv-i. 147-149.

N.B. I presume that Jacobi could not have overlooked albu-
minuria had this been present. T. C. A.

332 APPENDIX.

62. Fracture of base, amaurosis.

' M. G., set. 23, fell heavily, face downwards, upon the pavement.
Unconscious for two days, although he was promptly bled. Left
eye red with considerable sub-conjunctival haemorrhage ; the apo-
physis ascending from the left upper jaw presents a dislocation
upwards, and projects near the punctum lachrymale. The bones
of the nose are broken. Left eye blind and pupil dilated ; and
at first the eye was prominent and the sixth nerve palsied. The
cheek is insensible. The disk is atrophied. In one month health
was restored, and the right eye remained good, but the left re-
mained blind. Evidently there was a fracture near the foramen
which gives passage to the optic nerve, and which was thereby
compressed and atrophied.' Galezowski, loc. cit., pp. 142, 3.

63. Fracture of base of skull, ecchymosis into retina.

' E. C., carpenter, aet. 54, fell upon his head two days before
admission. Unconsciousness one hour, dizziness, and vomiting the
rest of the day. There is much ecchymosis about the right fronto-
parietal suture, at the root of the nose, in the eyelids, and con-
junctivas. Right eye absolutely blind.

' O. S. Its fundus is so red that the vessels are hardly to be seen :
at the inner and upper part of the disk is a striped haemorrhage ;
it is oblong, and directed upwards and inwards, being to the disk
as a tangent to a circle. Above and below it are two little whitish
streaks due to slight infiltration around the morbid product. Disk
intensely red, the vessels dilated ; one of them ends in the haemor-
rhage which probably plugs its ruptured end.

' There was a large escape of cerebrospinal fluid. The man re-
covered, but the eye remained weak/

Bousseau, 'Des Retinites secondaires,' p. 97. Paris, 1868.

64. Fracture of the skull, depressed, and probably compound ;
recovery, followed by optic neuritis and atrophy.

'Under the care of Dr. Slack, we saw a girl, get. 22, who had
become blind after a fall on the head. She stated that, five months
before our visit, she fell and struck her head against some sharp
portion of a wheel. She was insensible for about two hours, and
her nose bled. A day or two afterwards her eyes became blood-
shot. She was troubled with sickness for several clays after the

CASES 6265. 333

accident, but did not seem to have vomited blood. There was neither
deafness nor discharge from the ears. About four weeks after the
accident she suffered for several days from headache and sickness ;
and about the same time her sight began to fail, the right eye being
affected first. She stated that, simultaneously with the failure of
the right eye, she partially lost power on the right side ; but that
she afterwards quite regained it. The left eye afterwards became
affected in the same way as the right. She had no medical advice
for the injury to her head, but stated that there was a wound of
the scalp which bled somewhat. When we saw her there was a
depression, admitting the tip of the index finger, in the scalp,
nearly over the supero-posterior part of the right parietal bone.
She was quite blind. The pupils were widely dilated the right
somewhat more so than the left. In the right eye, the retinal
veins were congested and somewhat tortuous \ the disk was pale,
and its margins very indistinct, from the existence of semi-opaque
effusion, which, however, did not completely hide the vessels at
any point. In the left eye there were a crescent and myopic re-
fraction ; the retinal veins were markedly less distended than in
the right eye ; the disk was quite white j and there was no trace
of effusion.

' We are indebted to Dr. Haynes, the house-surgeon, for the
opportunity of seeing this case.'

' British Medical Journal,' March 12, 1870.

65. Abscess of right hemisphere, amaurosis, autopsy.
1 A boy, set. 4, under Dr. Peacock, had been ill three months
with convulsions and subsequent left hemiplegia. He had also
ptosis of right eyelid and dilatation of pupils ; the right eye was
blind, and the left eye became enfeebled. He died in convulsions
about three months later, the ptosis having disappeared. An
abscess containing eight ounces of pus was found in the right
middle cerebral lobe extending close to the convolutions. This was
surrounded by indurated tissue [the depth of which is not men-
tioned] containing compound granular corpuscles, and a few similar
corpuscles diverted in the right corpus striatum and thalamus.
There was some sub-arachnoid effusion and lymph on the surface
of the right hemisphere. Left side of brain, spine, and other
organs healthy. Dr. Peacock remarked upon the perfect pre-
servation of intelligence.' ' Pathol. Transact.' vol. xvii.

334 APPENDIX.

66. Abscess of posterior lobe, hydrocephalus, amaurosis.

1 A young girl, set. 5 years, was seized with general convulsions
eight days after the disappearance of measles. She had headache
on the right side, mouth drawn to the left, strabismus, and left
hemiplegia. During a few days at first she had thirst and heat of
skin. The palsied limbs are contracted and stiff, the others con-
stantly in movement. There was continual irritability, no stupor
or coma, hearing good, sight gone, pupils dilated ; the strabismus
was of the right side, and convergent. Latterly there was insensi-
bility and stertor. Death in three months.

'Autopsy. Dura and pia mater adherent on the right side.
Eight hemisphere swollen behind, the cerebral substance here being
firm and leathery. The posterior lobe was almost filled by a
globular sac which can be easily separated from the cerebral
substance. It contained four ounces of laudable pus. The ven-
tricles were distended with fluid.'

Bateman, 'Edinburgh Med. and Surg. Journal,' 1805, vol. i.
p. 150.

67. Abscess in right hemisphere, neuro-retinitis.
1 A girl, eet. 12, was admitted into Oppolzer's Ward in the winter
of 1864. She had received a blow upon the head which had pro-
duced unconsciousness. Symptoms of cerebritis gradually came
on, slowly increasing hemiplegia of the left side, with convulsions
at first of the palsied side, and afterwards of both sides. Facial
paralyses were noticed, sometimes on one side and sometimes on
the other ; the left pupil was dilated, and the superior and inferior
recti muscles were weakened. Amaurosis set in suddenly, and
neuro-retinitis was discovered. An abscess was found at the au-
topsy, which was seated closely over the right optic thalamus.'

Benedikt, ' Electro-therapie,' p. 257.

68. Softening of brain, amaurosis.

Rostan (' Recherches sur le Ramollissement du Cerveau,' 2nd ed.
obs. ii. pp. 28-31) records a case of softening of the brain. 'The
optic nerves were flattened, diminished in calibre, in a state of
atrophy, of reddish appearance, like a small arterial tube, and with-
out any resemblance to the whitish cord which they ordinarily
present.'

Quoted by Lawrence, p. 501, who does not say more about the
softening.

CASES 6670. 335

69. Hemiplegia, convulsions, neuro-retinitis, death,
mesocephalic softening.

'A soldier, set. 26, suffers from constant paroxysmal headache on
right frontal region. Is feeble and moves slowly. Mind clear, save
occasional hallucinations. Recent amblyopia.

4 O. S. The retina near each disk had lost its transparency,
and was grey and opaque, this opacity extending along the principal
vessels, and at times obscuring them. Numerous retinal ecchymoses
were scattered about the disks, growing less frequent near the
macula lutea. In the course of the next six months left hemi-
plegia and convulsions were followed by death. A month before
death there was no perception of light, but shortly before death
light was again perceived. There are no notes of subsequent ex-
aminations with the mirror.

' Autopsy. Softening and reddish grey discoloration first observed
over small space in cms cerebri, just anterior to pons varolii. This
the finger readily followed, without apparent tearing of brain tissue,
anteriorly into the white substance of the right hemisphere to the
distance of two or three inches. On this side the optic thalamus
and corpus striatum were so much involved in the morbid process
as to be scarcely traceable. The softest portions were pulpy but
not fluid ; and irregular greyish, reddish, or dull white limited
portions being also gelatinous and somewhat translucent. Under
the microscope the principal and quite uniform appearances were
broken down, curved, and distorted nerve-fibres, together with
abundance of free fat granules distinct and agglomerated, rarely
enclosed in cell walls. No pus or pyoid cells seen.'

Drs. H. Darby and Upham, ' Boston Med. and Surg. Jour.' v. 72,
p. 21, quoted in ' Ophthalmic Review,' vol. ii. p. 78.

70. Disease of cerebellum, amaurosis.

Boy, set. between 1 4 and 1 5 years ; very tall of his age. Until
six months before death had been quite healthy, living in south of
England. No hereditary taint of any sort. Came to Manchester
six months ago to enter business. A very quick, intelligent lad,
very anxious to get on ; learning French, &c. ; growing very fast.

Six months ago began to have occasional bilious vomiting, recur-
ring every three or four days. Eyesight soon began to fail, and
gradually, in course of three months, became totally blind of both
' eyes. Flesh and strength gradually failed ; but no actual paralysis

336 APPENDIX.

took place to the end of life. Trance-like attacks occurred once or
twice a week, lasting from fifteen to forty minutes, with total in-
sensibility, but without any convulsion. No irregularity of move-
ment, staggering (or titubation), occurred at any time, nor any
priapism. The trance-like attacks always followed the bilious vomit-
ing ; and all day after one of these attacks the lad would be heavy,
dull, and indifferent, not originating any conversation, and without
appetite or power to eat. On the days between these ' bad' days the
appetite was excellent, or rather, voracious, and the intelligence
remarkably brisk. He was cheerful, lively, laughing, wanting to
be read and talked to, learning French, and altogether remarkably
quick and smart (this applies to the last three months of life).
Hearing very quick, but the hearing of left ear somewhat impaired.
The pulse quick but regular. Tongue in last three weeks (being
the time he was under my observation) clean and fiery red, inclined
to be dry, but never actually dry, so far as I know. Patient lay at
this time with mouth invariably and continually open (gobemouche
fashion) ; perhaps this had something to do with the remarkable
state of tongue. He kept his bed for last three months of life from
exceeding weakness and great emaciation; nevertheless, he was
taken home from infirmary (2^ miles) in a cab, sitting up. He
could sit up in bed to near the time of death. Skin dry. Urine
contained neither sugar nor albumen. No chest symptoms. Occa-
sional violent headaches occurred, but nothing remarkable or con-
stant. He became insensible in last six hours of life.

Died Nov. 25, 1866. Autopsy. All organs outside skull healthy
(lungs, heart, liver, <fcc.) Cerebrum also healthy, but cerebellum exten-
sively diseased ; both lobes softened spotted on the surface with
small white spots the left lobe less diseased than the right. The
right lobe gave way on removing ; its central parts were very soft,
the white matter in places of consistence of cream. Under micro-
scope the nerve fibres are found totally destroyed in the softened
parts, and reduced to granular matter, with immense quantities of
'granular corpuscles,' and also numerous free oil globules. The
presence of ' granular corpuscles' could be traced into the crura
cerebelli, mixed with healthy-looking nerve fibres.

The white spots on surface were found to be masses of ' granular
corpuscles.'

There was general fatty degeneration of arteries at base of brain.
Communicated to the author by Dr. Roberts of Manchester.

CASES 7173. 337

71. Hcemorrhage pressing upon the ckiasma, blindness, autopsy.

' Mr. Stevenson was called to attend a patient between forty and
fifty years old, who was found lying on the ground in an apoplectic
fit. The pupils were dilated, and he was quite blind, but not
destitute of sensation and feeling. He expired within twelve hours
after the attack.

' Autopsy. Decisive marks of meningeal congestion : large accu-
mulation of discoloured serum in the ventricles, and a mass of
coagulated blood so placed as to compress the optic nerves at the
part where they decussate.'

Mackenzie, ' Diseases of the Eyes/ third ed. 1840, p. 874.

72. Headache, vomiting, amaurosis, haemorrhage into

various parts of encephalon.

'A man, set. 32, was seized at 10 a.m., while talking, with giddi-
ness, headache, and vomiting. He died in eleven weeks. Am-
blyopia noticed in three weeks ; eyes examined in tenth week, when
latter stages of neuritis were found. No palsy, some slight mental
confusion, which passed into stupidity two weeks before death.
Autopsy : Large hsemorrhage into middle cerebral lobe, and a few
specks in corpora quadrigemina.

Hughlings Jackson, 'R. 0. Hosp. Reports,' iv. 248.
Dr. Jackson regrets that further details are not in his possession.

73. Old mesocephalic hcemorrhage, amaurosis, autopsy, cyst
of thalamus and corpus striatum.

1 A woman named B-' had suffered eight years before admission
from right cerebral haemorrhage, with left hemiplegia which passed
off.

' Twenty-five days before admission lost anew the use of the left
limbs.

' On admission was found to be incompletely amaurotic. In a
few days she died, and the right striate body and thalamus were
found to be occupied by a kind of cyst which was empty and
flattened, and surrounded by softened nervous matter. The cms
cerebri is wasted, and also the lower stage of the pons, the anterior
column of the cord, and also the optic tract.' Lancereaux, loc. cit.

Also another case, ibid., in which, however, a cyst occupying
the same site and attended with amaurosis was probably the remains
of a blood clot.

z

338 APPENDIX.

74. Hcemorrhage, hemiplegia, amaurosis, old clot near the

thalamus.

Decaufflet, set. 68, had an attack of right hemiplegia five years
before admission, and his left eye was dim. He was admitted for
bronchitis, and died in a few days. Atrophy of the left disk was
seen with the mirror.

' Autopsy. Heart hypertrophied.

' Encephalon. In the left hemisphere, just above the thalamus, a
portion of the small brain is " molle-celluleuse," and of an ochrey
yellow colour. There was no cavity. It seemed to be the remains
of a haemorrhage cicatrised and coloured by altered blood. The
optic nerve is atrophied up to the chiasma. The cerebral arteries
are ossified.'

Bouchut, * Diagnostic des Mai. d. SystSme nerveux par 1'Ophthal-
moscopie,' p. 208.

(No mention is made of the right nerve or disk, and I very much
doubt the connection of this unilateral atrophy with the haemorrhage.
More details should have been given concerning the date of the
loss of vision, and some other points. T. C. A.)

75. Hcemorrhage into brain, hemiopia.

Zagorski gives an account of a female patient, set. 37, who pre-
sented herself at the Eye-clinic in Basel with hemiopic deficiency
on the right side in both eyes, and left facial paralysis and hemi-
plegia. The attack came on suddenly with unconsciousness eight
days before, and was clearly a hsemorrhagic effusion into the right
hemisphere. The deficiency in vision was completely restored in
a few weeks.

' Monatsbl. f. Augenh.' October 1867, pp. 322-325.

Several cases of this kind are on record. There is one, for ex-
ample, in Grafe's well-known lecture in the ' Klin. Mon. Zehender,'
of a man, set. 68, who suffered from apoplexy with left hemiplegia
and hemiopia. The right half of each disk was found to be atrophied
and retracted three years after the event, though five months after
it no change in the disks could be discovered.

76. Clot in cerebellum, amaurosis.

1 A girl, set. 1 8, ten years before her death, had an attack of
apoplexy, the result of which was amaurosis without any other

CASES 7478. 339

paralysis, and habitual headache. An apoplectic cavity of old
standing was found in the right lobe of the cerebellum.'

Andral, ' Clin. Medicine.' Quoted by Dr. Hughlings Jackson,
<B. L. 0. H. Beports,' iv. 18.

77. Optic atrophy, 'sick headaches,' past history of cerebral

disease and Jits, also of transient hemiplegia.

Margaret S , set. 53, consulted the author at the Dispensary

on March 2, 1868, for sick headaches. She did not complain of her
sight, nor did she allude to any more serious cerebral symptoms. Had
I not fortunately examined her eyes, I should not have suspected any-
thing more than neuralgia, and the case is published as a warning.
The attacks of headache occur in one or other temple, and are
preceded by a ' swelling of the vein (temporal artery, T. C. A.) as
big as her finger.' They recur about once a month, are attended
with some nausea, and last about twenty -four hours. They generally
set in at about 2 a. m.

O. S. Both disks are atrophied, the more central parts being
greyish brown, and the grey white atrophy invading from the
circumference. Admits that her sight has grown worse of late.

On further inquiry I find that she has been accused of failing
memory. There was some little want of facial symmetry, the left
side being a little the stronger. There is slight ptosis of right eye ;
orbital muscles and iris normal. There is no evidence that this
is recent 2 . At the age of 14, had ' water on the brain with inflam-
mation/ for which she was treated by Mr. Garlick. Had fits
occasionally, ever since, until the change of life, about three or
four years ago. Has had none since. Many years ago two of the
fits left right hemiplegia, which lasted three days, and did not affect
the speech.

78. Optic atrophy, probably preceded by subacute neuritis,

previous history of hemiplegic attack.

Hannah L , set. 38, applied to the author by accident at the

Leeds Dispensary, instead of going to the room of his surgical col-
league. Complained on application (Feb. 17, 1868) of defective
vision, which had begun to give her much anxiety. Her right eye
said to be the worse.

3 I have noticed some ptosis and loss of facial symmetry in several old
sufferers from neuralgia. T. C. A.

Z 2

340 APPENDIX.

O. S. Right disk much whiter than left disk and decidedly
atrophic. Left disk whitish and rather blurred. Vessels very
abundant.

This person applied entirely on account of her eyes, and it was
only after a somewhat severe cross-examination, in which, however,
all leading questions were avoided, that the following details were
obtained. The case, like the former and the following one, is
useful only as an example of the difficulties of medical ophthal-
moscopy.

Three years and a half ago suffered from pain in head for about
six months. She then recovered, and three years after was again in
perfect health, and sitting in her chair one evening, when she felt
the left arm grow suddenly ' numb and weak,' so that her market-
basket fell out of her hand. She tried to rise from her chair, and
then fell all her length upon the floor. Says she did not lose con-
sciousness, and tried ' to sam herself up' but could not, and her
husband had to raise her. She was then hemiplegic. The leg
recovered in a day or two, but the arm remained weak and the
fingers ' drawn up' for perhaps two months. She then completely
recovered, and has since been in good health. So that it is only
by an effort of memory that she recalls the above facts.

79. Amaurosis first unilateral, then bilateral, subsequent

cerebral disease.

This case is recorded for two reasons : first, to show, what I have
said repeatedly in the body of the work, that atrophy of the optic
nerve is often a forerunner of other symptoms of encephalic or spinal
disease. MacCarthy was for a few months a porter at the Leeds
dispensary, and then was suffering from atrophy of the left optic
disk. The unilateral character of it was curious, and he was there-
fore seen by Mr. Teale, Mr. Oglesby, and other observers. It was
not until months afterwards that the other eye went in the same
way, and now he began to have occasional ' bilious attacks,' head-
ache, and vomiting. These, however, had so little unusual in them,
that, interested as I was in the case, I should not have discovered
this had he not been one day absent from his duties on account
of an attack. Shortly after he left the dispensary, and a year
or more must have elapsed before I espied him in the medical
wards of the infirmary, under Dr. Heaton's care for manifest
encephalic disease. He was suffering under considerable paralysis

CASES 7981. 341

of all four limbs, and had headache and vomiting. The case is
suggestive of cerebellar disease ; but I need not enter into this,
as there is as yet no autopsy, and the point of interest the long
antecedence of amaurosis is established.

8O. Aneurism of anterior cerebral artery.

A man, set. 37, became suddenly insensible while at work, but
quickly recovered and resumed his work. In three weeks had another
fit, and remained in stupor three or four days. Seems dejected,
sallow, and morose, and complains of vertical headache made worse
by stooping. Pupils dilated but act under light. Some days after-
wards became suddenly comatose and stertorous, and died next
morning.

Autopsy. Extravasations of blood in various parts of encephalon,
and an aneurism of the right anterior cerebral artery the size of a
hazel nut was found pressing upon the right optic nerve. It had
burst into the lateral ventricle.

As there was cataract of the man's right eye its blindness cannot
be referred to the aneurism, but the case is useful as showing how
such an aneurism may affect the optic nerve.

Abbreviated from Mackenzie, third ed. 1840, p. 877.

81. Tumours of anterior lobe, meningitis, amaurosis,
autopsy.

Mrs. E. P. of Barnsley. Admitted into Leeds Infirmary under
the author on Aug. 6, 1870.

Family history good.

Personal history good till three and a half years ago, when dull,
aching, constant headache and morning sickness set in. Sight has
been affected for about nine months, and has lately become much
worse. She is now indeed almost blind, and has white atrophy
of both nerves. A general weakness of the limbs without definite
palsy came on at the same time and now continues. On admission
she is incoherent in ideas, and jumbles words. She speaks very
slowly, but is scarcely intelligible. Died Sept. 18.

Autopsy. Two small superficial tumours, about the size of beans,
in the anterior lobe of the right hemisphere. Brain substance
around them much degenerated ; evidences of proliferation slight
save on the surface. There is adhesive meningitis all over the
anterior lobe both above and below. All the membranes are

342 APPENDIX.

adherent to the orbital plates below, and the adhesions extend as
far as the chiasma, the loss of sight being due no doubt to an
adhesive basilar meningitis.

82. Grlioma of left anterior cerebral lobe, double optic neuritis.

'A man, aet. 23, under the care of Dr. Ramskill, had convulsive
attacks ; he suffered intense pain in his head, and there was double
optic neuritis. It was almost certain from these symptoms that
there was intra- cranial tumour. He was doing very well, being
about the ward. He had a good appetite, and was able to read,
when one night he was seized with a convulsion, became very
deeply comatose, and died in two or three hours. Dr. Sutton
found at the autopsy a gliomatous tumour of the fore part of the
left anterior cerebral lobe, with recent effusion of blood to the
extent of several ounces.'

Hughlings Jackson, 'Lancet/ Oct. 23, 1869.

83. Case ofhydatid cyst in the right cerebral hemisphere.
(Manchester Royal Infirmary, under the care of DE. MOEGAN.)
* The subject of this case was a little girl, set. 7, who was admitted
into the Manchester Royal Infirmary on November 22, 1869,
and died February i, 1870. At the time of her admission, it
appeared that the patient had been ill for nine months, her illness
commencing with convulsive seizures. These seizures were suc-
ceeded by paralysis of the lower extremities ; the pupils were both
considerably dilated, though there was no paralysis of the muscles
of the eyeballs on either side. Her sight was much affected ; there
was no apparent loss of cutaneous sensibility. During the last four
weeks of her life she was comatose ; she became gradually weaker,
and died February i, 1870.

' Inspection sixty hours after death. On removing the calvarium,
nothing unusual was observed ; but, as soon as the dura mater was
detached, a considerable portion of the cyst was seen lying imme-
diately below it in the right cerebral hemisphere. On removing
the brain from the skull, this cyst readily slipped out from the
cerebral hemisphere, without discharging any of its contents. The
cyst had occupied the anterior and middle lobe of the hemisphere,
extending inwards to the lateral ventricle. A considerable portion
of the corpus striatum and part of the optic thalamus were ab-
sorbed from pressure of the cyst. There was no softening or dis-

GASES 8285. 343

ease of any portion of the brain surrounding the cyst. There was
no fluid in the right lateral ventricle ; but that on the left side
contained about an ounce of clear serum. In other respects the
brain was perfectly healthy. The cyst weighed 18^ ounces, and
contained 18 ounces of clear fluid. The fluid had a faint alkaline
reaction. Specific gravity, ion. Under the microscope numerous
echinococci and detached booklets were founded.'

' British Medical Journal,' June 18, 1870.

84. Tumour of middle lobe, neuritis, autopsy.

An encysted tumour about the size of a mandarin orange, and
weighing three and a half drachms, was shown to the author lately by
Mr. W. N. Price. It had been removed from Miss F., who during
life had suffered from anaemia, and from much neuralgia in the
head and face. She had also transient numbness of the right side,
with giddiness, some weeks before death. The only marked symptom
was blindness, which followed optic neuritis of both eyes. The notes
of the autopsy are very inadequate. The tumour was found in the
upper and outer part of the left middle lobe of the cerebrum;
* effusion -like lymph' surrounded it, and the brain substance was
extensively softened. The tumour did not seem to be truly en-
cysted, but was like a mass of old tubercle.

A brother and a sister had died of tuberculosis.

85. Headache, vomiting, convulsion, optic neuritis, hydatid
of left hemisphere.

R. B., set. 8, had been ill eight or nine months with occasional
headache. After an interval of some weeks the headache returned
with great severity, generally coming on at 4 a. m. and remitting
at 10 a. m., when there was vomiting. Weak sight six weeks before
observation on April 9, 1867. Convulsions a month ago, and occa-
sionally since ; obvious but slight weakness of right arm, side, and
leg. Died in stupor, April 26.

O. S. April 23. Disks dirty white, swollen; veins irregular,
partly buried in swollen disk. Disks no real boundary, gradually
melting into fundus. (Ischsemia.)

Autopsy. Cyst in posterior half of left hemisphere, lined by
gelatinous firm wall, one fifth of an inch thick. Wall tore easily,
and was separable from brain substance. Lateral ventricles
' dilated' (with fluid?) and bones of skull tending to separate.

344 APPENDIX.

Cavity extended forwards to middle of ascending parietal convo-
lution and backwards to end of outer wall of posterior cornu.

Abbreviated from Hughlings Jackson, ' London Hosp. Reports,'
vol. iv. p. 391.

86. Blow on head, tumour of right hemisphere, atrophy of disks.

Mr. Handcock has been so kind as to forward to the author the
following notes of this case :

' I fear I cannot give you very ample details in reference to the
boy you saw with Mr. Teale and myself in Accommodation Road.
His name was John S., set. roj years, and he died on September
the 1 6th, 1867, one year and seven months after receiving a blow
with a stone on the right side of the head. He had always enjoyed
perfect health before that time ; nor is there any hereditary ten-
dency to scrofula in the family. Soon after the blow he began to
complain of pain in the part where he was struck, and in a few
weeks the headache became at times so severe as to cause him
to shriek with the severity of the pain. These severe attacks
of pain came on every two or three weeks, were attended with
vomiting, and generally lasted a day or two. In the intervals
he was able to walk about, but was observed to drag the left leg.
He then gradually lost the sight of the right eye, and the pupil
became fully dilated. During the last nine months of his illness
he became hemiplegic on the left side, lost power over his bladder,
and became totally blind. His hearing was preternaturally sharp,
and his memory was not much impaired.'

When seen by Mr. Teaie and myself, the optic disks were quite
atrophied. We found a tumour, a loosely-built sarcoma, in the
posterior lobe of the right hemisphere. It was about the size of a
pigeon's egg. The brain around for a short distance was softened,
but the rest of the encephalon and the membranes were healthy.

87. Tumour of base of encephalon, blindness of right eye, autopsy.

This case is related by Dr. G . A. Rees in the fourth volume of
the ' Pathol. Transactions.' It cannot be cited as an instance of
unilateral optic change, as the mirror was not used. The right eye
was blind, and the state of the left is not mentioned. It is a
remarkable instance of the way in which such tumours grow and
involve successive parts. It was pear-shaped, about 3" long, and
J:"&t its greatest diameter. The right optic nerve was lost, the

CASES 8689. 345

left was adherent to the side of the tumour and considerably
diverted. It seems, from the rigidity of the arm observed at the
outset, to have commenced near the right crus cerebri, and as
it extended itself forwards so it involved the optic nerve, the third
pair, the right olfactory lobe (also gone), and the grey matter of
the right anterior lobe, as was marked by loss of vision, strabismus,
and subsequently impaired intellect.

88. Tumour of crus cerebri, double optic neuritis.

A boy, set. 9, was under Dr. Hughlings Jackson's care at the
London Hospital, for paralysis of the third nerve on one side, and
hemiplegia on the other. These symptoms had come on slowly
with headache ; and there was a double optic neuritis. He died
during the night, of effusion of blood from a tumour of the crus
cerebri, which caused the paralytic symptoms. The palsy of the
third nerve on one side, and of the arm and leg on the other,
pointed to disease of the crus cerebri. The gradual onset of the
paralysis, and its complication with optic neuritis, made it certain
that the disease was of some coarse kind. The age of the patient
rendered it most probable that this coarse disease was tumour.
His sudden death led to the inference of haemorrhage from tumour.
Hughlings Jackson, 'Lancet,' Oct. 23, 1869.

N.B. I have been so fearful of leaving my main subject, that I
have not discussed points in diagnosis of tumours which were not
ophthalmoscopic. I may say, however, that I have twice seen
sudden coma and death following some convulsions in cases of
simple tumour without haemorrhage. Such a case, for instance, is
recorded in the 'Catalogue of S. Geo. Museum,' No. 187, p. 392.

89. Tumour of corpora quadrigemina, amaurosis.

<E. S., et. 27. Amblyopia one month with headache, both eyes
being affected. She could only count figures close 'at hand. The
disk was greyish and very prominent, its margin invisible. Veins
moderately congested. Iodide of potassium ordered. In a short
time she was Hind, and in a few weeks vomiting, voracity, consti-
pation, and dysuria set in, with attacks of loss of consciousness and
slight twitchings. There was gradually augmenting deafness, and
towards the end she was violently delirious. She died four months
after admission. The state of the pupils is not mentioned.

' Autopsy. Great and general congestion both of the sinuses and

346 APPENDIX.

of the brain. A neoplasm extends from the corpora quadrigemina
into the interior of the pons varolii. The region of the corpora
quadrigemina consists ^almost entirely of connective tissue ; this
proliferation has no distinct limits where it extends into the pons.
Scattered through the neoplasm are the elements of tubercle.'

W. Wagner, 'Klin. Monatsbl. f. Augenh.' 1865, p. 159; quoted
in ' Ophth. Review,' ii. 404.

90. Amaurosis with dilated pupils, general palsy, tumours of
corpora quadrigemina.

'A man, set. 30, had complained for a year of severe headache,
loss of memory, dimness of both eyes, and faintness. Aspect
cachectic, dull in reply, pupils much dilated and sluggish, all
objects appear misty. Gait feeble, and is soon wearied, hand-
pressure weak, drowsiness alternates with twitchings of limbs
and objectless cough. In a few days sank into a stupid state,
and died completely paralytic.

'Autopsy. Inner membranes infiltrated with serum, convolutions
flattened, ventricles distended. In corpora quadrigemina a medul-
lary growth about the size of a nut, which separated the thalami
from each other and sent a small conical process into the fourth
ventricle.' Rosenthal, ' Nervenkrankheiten,' p. 83.

91. Tumour of cms cerebelli ad pontem, neuritis, autopsy.
A man, set. 37, came under Mauthner's care with a fully de-
veloped neuritis in both eyes ('in beiden Augen das vollkommen
entwickelte Bild der Neuritis ' ). His sight was tested and found
to be perfect. This man enjoyed full acuteness of vision (' dieser
vollen Sehscharfe erfreute ' ) until the end of his life. He died sud-
denly. A tumour was found (a sarcoma of the size of a walnut) in
the right cru cerebelli ad pontem, together with a considerable
dropsy of the ventricles. Papillary neuritis was found, with thick-
ening of the connective tissue, the layers of the retina up to the
papilla being normal. Mauthner, ' Lehrbuch,' p. 293.

92. Tumour of cerebellum, ischcemia papillae, vence Galeni turgid.

Dr. Simpson, of Manchester, read notes of a case of cerebral

disease of much interest. The patient was a boy aged 1 4, who, up

to the end of 1869, had enjoyed good health, and whose family

CASES 0093. 347

history was satisfactory. About Christmas, he began to complain of
severe shooting pain at the back of the head, intermittent in cha-
racter, and at times so severe as to make him scream out. Soon
afterwards be began to vomit ; at first in the morning, but subse-
quently also after his meals. The vomiting was unaccompanied by
nausea. His bowels became very costive. He continued in this
state for some time, when, about the middle of April, he began to
have a dull, heavy expression, and also showed some difficulty in
walking and articulating. It soon became evident that his sight
was becoming impaired, and though he remained fairly intelligent,
his memory became very defective. There was slight paralysis of
the internal rectus of the left eye. The symptoms gradually became
worse. His gait was not that of paralysis, but of want of co-ordi-
nating power.

O. S. On July 25, his eyes were examined with the oph-
thalmoscope by Mr. Windsor, who reported a large and swollen
condition of the optic disk, with no distinct boundary, a swollen
and tortuous condition of the veins, and other evidence of intra-
cranial pressure. His progress was steadily downward, and he
died on September 17, comatose. At the post 'mortem exami-
nation, the head only could be examined. The veins of the dura
mater were turgid, and the visceral arachnoid rather thick and
opaque ; and there were several ounces of slightly turbid cerebro-
spinal fluid. There was a little lymph about the optic commissure
and anterior margin of the pons. The venae Galeni were very
turgid. The whole brain substance was softened, particularly the
parts at the base. Both lobes of the cerebellum contained numerous
yellow masses of tubercle, varying in size from a pea to a marble.
No tubercle was found elsewhere in the brain, and during life there
was no evidence of its presence in any other organ. Dr. Simpson
referred to the question of diagnosis, and discussed particularly the
differential diagnosis of tubercle and hydatid cyst of the brain.

1 British Med. Journal/ Oct. 22, 1870.

93. Palsy of recti externi, neuro-retinitis, death, tumour
of pons.

'Franz Kothasek, typesetter, set. 38, admitted into Oppolzer's
wards on Feb. 13, 1865. Headache some years. Severe headache
in forehead, temples, and occiput for seven weeks. Vomiting

348 APPENDIX.

for eight days, amblyopia, which set in suddenly, for five weeks.
Eight eye quite blind, left highly amblyopic.

1 Dizziness prevents his standing. Pulse 135.

'0. S. (by Dr. Eydel). Bilateral neuro-retinitis, with numerous
oval haemorrhages, especially in right. Disks swollen, turbid,
blurred. Both external recti palsied.

1 Improved on galvanism of the sympathetic.

'In the summer and autumn returned with headache, and
tubercle of lungs and larynx. Weakness of extremities without
definite palsy came on, and death took place on December 23.

' Autopsy. Besides tubercle elsewhere was found in the head
calvaria thick and compact ; dura mater stretched, inner mem-
branes rather infiltrated with serum and easily removed. Brain
somewhat moist and firm. Lining of ventricles thickened and half
an ounce of serum in the cavities. In the lower half of the left
anterior portion of the pons a round firm cheesy tubercle the size
of a cherry. The lump had penetrated to the base, and had grown
from the deep transverse layer of the pons and pressed aside the
strands of the pyramids without destroying them.'

Benedikt, ' Elektrotherapie,' pp. 257, 258.

94. Railway accident, changes in thefundus, amblyopia,
spinal injury.

Mr. C. was seen by the author in consultation with Mr. Teale of
Leeds, the late Dr. Garlick of Halifax, and Mr. Hiley of Elland, on
Jan. 1 8, 1868. In March 1867 he had received a concussion in a
railway accident, which caused some unconsciousness and some in-
jury to the spine. Soon after, his sight, which was of much import-
ance to him in business, began to fail. When we saw him he had
fever, great dizziness, some delirium, some incontinence of urine,
sexual impotence and priapism ; also severe shooting pains in the
legs, which however were not palsied. He had two definite and
acutely tender points in the back, one about the seventh cervical
vertebrae, the other over the last three lumbar vertebrae.

O. S. Pupils equal and sensitive to light. Beads large primer
with difficulty. Fundus in both eyes very much altered. There
is no trace of a disk, the whole of this region being of a reddish
injected appearance, the red in the right eye having a daffodil tint
a sort of yellowish pink. The retinal veins were full and dark,
and the arteries, as such, were indistinguishable.

CASES 9497. 349

95. Railway accident, spinal injury, vascularity of disks.

Mr. L was a patient of Mr. Seaton of Leeds, and was seen

likewise by Mr. Teale and the author. The case was a most interest-
ing one, and will I hope be published by Mr. Seaton. It is only to
the point at present to say that when we saw him together he was
utterly paraplegic both of motion and sensation, and in daily fever.
The cerebral functions were also much disturbed, hallucinations
and delirium being very frequent. There were the two tender
points on the spine, which are so commonly found in these cases,
namely, one in the lumbar, the other in the lower cervical and upper
dorsal region. I saw him two months after the accident.

O. S. Both retinas were hypervascular, the disks were slightly
veiled by exudation, and their edges thereby also a little dimmed.

96. Railway concussion, arriblyopia, suffused disks.

Mr. S. was seen by Mr. Teale and the author on the 23rd of
August, 1866, and the fundus was drawn by Mr. Aldridge.

Five weeks before, he had a concussion in a railway accident, but
did not seem to be much hurt at the time. He believes now that
his back was struck, and it is very tender to pressure over the sixth
and ninth dorsal vertebrae. He is now depressed, confused in mind,
and easily fatigued. After talking to us for half an hour, his words
run into one another.

His sight, excellent before the accident, is now dim. He cannot
read No. i Jager, but reads No. 3 with difficulty, aided by a No. 20
convex lens. Soon after the accident his pupils were dilated and
sluggish. At present the left pupil is normal, but the right dilated,
and acting slowly through the medium of the left.

O. S. Right eye. Disk suffused, no margins visible, some oedema
about and upon the disk, veins of retina tortuous, those passing
downwards very tortuous.

Left eye. As right, except that the vessels of the retina, though
full and dark, are not tortuous.

I never saw this patient again.

97. Injury to neck, paraplegia, hypercemia of optic disks.

S , of Kippax, came to the author at the infirmary,

complaining of palsies which had followed a blow on the head.
Finding that the palsies were spinal, it was soon made out that the
blow on the head was the result of a heavy fall upon it, the fall

350 APPENDIX.

severely twisting and spraining the cervical vertebrae. Over the
fourth and fifth vertebras there was thickening and much tenderness,
of which he was aware, but had not supposed it to be of importance.
He was weakened in arms and legs, and had abnormal sensations.
There was occasional priapism and vesical derangement. The case
closely resembled a common kind of railway injury.

0. S. About five weeks after the injury both disks became hyper-
semic and somewhat suffused, the whole of this part of the fundus
being of a uniform yellowish red. The disks were indicated by the
convergence of a number of new small veins. The field of vision
was not contracted, but perception was decidedly diminished.

98. Cwries of the spine, cerebro-spinal meningitis.

The next autopsy was on the body of a female who had been for
many months in the hospital suffering from psoas abscess. On
opening the head, the arachnoid appeared greasy, and a quantity of
pus was seen running along the upper part of the hemispheres ;
and there was a quantity of puriform-looking lymph under the pia
mater at the base of the skull between the optic commissure and
the medulla oblongata. The brain-substance was firm, excepting the
parts forming the lateral ventricles, the fornix, the septum lucidum,
and the surfaces of the corpora striata and optic thalami, which were
softened ; and there was an excess of fluid in the lateral ventricles.
The softening of these parts, and the quantity of lymph at the base
of the brain beneath the pia mater, looked, at first sight, like tuber-
cular meningitis ; but the pus seen running on the lateral parts of
the hemispheres were unlike tubercular disease. The membranes
were carefully examined, and no tubercle was present. As there
was no disease of the brain-substance or tubercle in the membranes
to account for the pus being beneath the pia mater, it was sus-
pected that the disease had extended upwards from the spinal
canal. On examining the spinal cord, a quantity of puriform
lymph was seen extending from the lumbar region to the base of
the brain, and the bodies of the lumbar vertebrae were in the con-
dition known as caries, and in the substance of each psoas muscle
was a collection of pus.

About two days before this patient died, she complained of great
pain across the forehead, and vomited ; delirium of a very active
kind set in ; there was retention of urine ; the patient was very
restless, and moved her arms and legs about a great deal. Con-

CASES 98100. 351

sidering the great amount of disease all around the cord, it is in-
teresting to note that there was no marked or complete paralysis :
at the same time, it must be remembered that the surface of the
cord only was affected, and that its substance was not softened.
1 British Medical Journal,' July 2, 1870.

99. Spinal disease (caries), hypercemia of disks.

C. S., aet. 37. Admitted under the author's care October 16, 1868.
Three years ago, when in health, was struck with a brush handle
on back of neck. Some few weeks after, much stiffness was noticed,
and intense pains striking down into both shoulders and arms and
up the occiput to the vertex. A tumour was then said to have
appeared at the back of the throat, which caused difficulty in
swallowing and regurgitation of fluids through the nose. This
swelling ' burst ' and disappeared. He remained some weeks under
observation, during which time the arms became much palsied and
the legs rather weak. He had intense occipital and vertical head-
aches, with vomiting. There was thickening and tenderness over
the middle cervical region, and he referred the pain of movements
to this part. He obtained little benefit, and we lost sight of him
after about five months, his state being decidedly worse than on
admission.

O. S. During all this time both disks were highly hyperaemic
and troubled. Margins invisible. Retinal veins large. No marked
prominence of disks. There was some deficiency of visual power
with small types. The right disk was always rather worse than
the left. Pupils a little dilated.

100. Spinal disease, with optic signs.

B. B. A , set. 3^, 12 East Street. Leeds Infirmary, April 13,

1868. Pale, weakly child, with somewhat scrofulous history. Six
months ago an enlargement appeared in the lower cervical region
of spine. There is now great distortion there, bringing the third
and seventh cervical spine up to the occiput. There is much
neuralgia, and some weakness of all four limbs. Has one or two
enlarged glands under neck.

R. Veins decidedly large, but not very dark, and the disk looks
misty. The edges can however be made out.

L. As R., except that edges of disk cannot be seen. The disk
is not however much swollen. There is a decided amount of light

352 APPENDIX.

suffusion without any very dense opacity over a wide belt of
retina.

The sight is reported to be decidedly affected ; the child thinks
there are ' clouds in his eyes/ as his mother says. But he can dis-
tinguish objects well enough.

101. Injury to nape, disease of vertebrae, palsy of sympathetic
nerve, ophthalmic signs.

Johnny was long a favourite patient under the author's

care, and his symptoms were most interesting. Struck by a big boy
upon the 4-6 cervical vertebrse, his strumous habit was unable to
repair the mischief, and caries set in. Paraplegia of arms and legs
and bladder then appeared, and the body wasted below the seat
of injury. Some weeks after appeared also palsy of the left cer-
vical sympathetic. This depended upon the pressure of morbid
products, and varied therewith. During three weeks it transferred
itself to the other side, the left side symptoms disappearing. These
on either side were heat of cheek and ear, often amounting to an
excess of 5 or 6 (C) over the other side, hypersemia of the same
region, and undilateable pupil. A month before the appearance of
these changes, the ophthalmoscope had showed injection and slight
suffusion of the disk and neighbouring retina. These appearances
remained constant, and showed no variation with the inconstancy
of the heat and hypersemia of the neck, cheek, and ear.

102. Myelitis, subsequent atrophy of disks.
Christopher B., set. 26, admitted under the author's care on Nov. 2,
1866. He was a long time under notice, and the case excited much
interest, as he undoubtedly suffered from severe acute myelitis,
with bed-sores and complete paraplegia, and yet recovered. The
bed-sores began to heal about Dec. 4, and during the many fol-
lowing weeks he slowly regained power. As he regained power
his optic disks began to whiten and the vessels to wane. This
atrophy, however, seemed not to progress into the third stage, not,
that is, during the few months he remained under observation. The
field of vision was lessened decidedly, but central vision remained
fairly good. He was unable to read the newspaper, however, for
more than a few minutes, and he had some teasing scotomata. We
lost sight of him about the middle of 1867.

CASES 101105. 353

103. Chronic disease of the cord, atrophy of optic disks.

R. B. was sent to the author by Mr. Sedgwick, of Boroughbridge,
on June 3, 1869, complaining of paraplegia. It was incomplete, but
sensation and motion were both decidedly impaired. His symptoms
set in about twelve months before. He now reeled in his walk, and
the bladder was partially palsied. There were no special symptoms
of locomotor ataxy.

O. S. Atrophy of optic nerves in both eyes. Central vision
somewhat impaired, and visual field contracted. Vessels small and
waning. No evidence of foregone neuritis, acute or chronic.

Improvement of both sight and legs under careful Faradisation
and the use of iodide of potassium.

104. Paraplegia, hypercemia of disks.

Ann C , set. 50, admitted under me on Sept. 4, 1868.

Debility for two years, and some loss of appetite and flesh in con-
sequence of a severe fall, which hurt her back in upper dorsal
region. No local weakness till four months ago, when numbness
and pricking with weakness invaded the legs, and extended to the
lower part of the trunk. At the same time shooting pains down
back and legs, like those of ataxy, set in ; they also passed down
left arm. On admission, there is a point of the spine about the
first two dorsal vertebrae which is acutely tender on pressure. No
distortion, unless some prominence of the spines. There is decided
weakness of both legs, though she can stand; also of left arm.
Sensation to touch deficient; feels as if walking on wool. No
marked ataxic symptoms. Left arm feels ' as if covered up.'

0. S. Examination on admission. Right optic disk suffused and
pink, edges invisible, retinal vessels natural in size. Left optic
disk as right, but not quite so much disordered. Pupils not con-
tracted.

O. S. Examination three months later. Disks have been gra-
dually changing from red suffusion to greyness. Edges still invisible.
Vascularity less. Now there is weakness of both arms, and fre-
quent spasmodic contraction of left arm. She left the house, and
has since disappeared.

106. Locomotor ataxy, chronic optic neuritis.

Jane F , set. 28, was admitted into the Leeds Infirmary in

January, 1868. She has lancinating pains and loss of sensation in

A a

354 APPENDIX.

the feet and lower legs, as tested by the compasses, &c. She feels
as if she were walking on cushions, and is scarcely conscious of any
inequalities in the ground on which she walks. She loses her legs
in bed, especially if they be crossed. She can walk with fair
readiness and speed, if she may look at her feet, and may run the
tips of her fingers along the wall. Put her feet together and she
totters ; close her eyes and she falls. There is little or no loss of
muscular power. She says she has no loss of vision whatever, nor
does she seem to have on testing her with types. The pupils are a
little contracted. On dilatation, I found the disks whiter than
natural, the veins a little larger, the arteries smaller, and decided
marks of exudation both on the margins of the disks and dotted
closely around them. Mr. Teale kindly verified this observation
for me.

100. Neuralgia, with evidence of disturbance of cervical sympa-
thetic, disks normal.

Mrs. M. A. J., set. 26, came under the author's care in June, 1868.
For five years has been subject to the exhaustion of bleeding piles,
which are now cured. Three years ago suffered also from an attack
like the present. Four months ago was confined, and is suckling
the baby. She now suffers from very intense pain in all branches of
the fifth nerve on the right side. When the attacks come on she
has (as we have many opportunities of seeing) a contracted pupil,
and she sweats profusely (to her own great annoyance) on the right
face, neck and shoulder, so that water runs off her and wets all the
clothing in this region. The sweating and pain are generally syn-
chronous, but not always. The right vocal cord is also paralysed, as
seen with the laryngoscope. Under the use of hypodermic morphia
and of quinine, with iron and valerian, she improved much, the
pain departing first. A numbness of the right side of the face
outlived the pain for some weeks, and the unilateral sweating also
occurred occasionally without pain for some time.

O. S. The disks, dilated with atropine, were repeatedly examined,
both during the paroxysms and between them, but never detected
anything abnormal, unless it were some degree of persistent anaemia,
which was visible also in the mucous membranes and elsewhere.

107. Scarletina, Bright's disease, retinitis, recovery.
' A lad, set. 1 4, had suffered from scarletina, Bright's disease, and

GASES 106108. 355

retinitis six years before ; at that time the visual power was only
quantitative. A year later he appeared healthy, and by means of
weak convex glasses was able to do school tasks. No change in
vision has occurred during the last four years. He is now a
powerful athletic boy, and the heart and urine are normal. The
visual field is normal. The remaining amblyopia, which was accu-
rately noted, was accounted for by the dull white colour of the
disks, which are indistinct ; around them is a dullish white ring
with some white patches at its edge. The rest of the fundus is
normal/ Horing, quoted in the 'Oph. Review,' i. 159.

108. Scarletina, alhuminuria, retinitis.
(Under the care of DR. RUSSELL, of Birmingham.)

' A man, set. 34, was admitted February, 1869, with symptoms of
four months' duration, dating from an attack of scarletina. He
continued under care till the end of September, when he left im-
proved. His symptoms were, anaemia, considerable anasarca, with
tendency to effusion into the cavities. The urine was copious, at
times reaching seventy ounces; specific gravity 1012-20; the
albumen from one-fifth to two-thirds the bulk of the urine. The
urine presented sometimes intracellular transparent casts ; some-
times a copious deposit of fibrinous casts of small and full size, with
numerous fat-cells. At his admission he read Jager's No. i
brilliant.

O. S. 'Examination, March 2oth. The retina was bluish white
and cedematous. There were several small glistening specks around
the yellow spot. The veins were tortuous and swollen.

' April 24th. The changes in each eye had advanced consider-
ably, especially in the left, where the disk was scarce distinguish-
able, except by the entrance of the vessels. There were a few
minute haemorrhages, and white glistening spots, chiefly around
the yellow spot and the entrance of the optic nerve.

' May 2oth. The outline of the left optic disk had cleared, but
that of the right eye was so obscure, that it could scarcely be made
out. There were blood-specks and white spots.

'Sept. 1 3th. Both disks were obscure ; the veins full and tor-
tuous. The left retina was so much flecked with small glistening
white specks as to seem dappled. Here and there were traces of

old extravasation/

' British Medical Journal,' January 15, 1870.

A a 2

356 APPENDIX.

109. Albuminuria, retinitis.

Edward Thomas H , set. 40, was admitted, July 1867, under

Dr. Johnson, with Bright's disease. He applied on October 24
to Mr. Soelberg Wells about his sight, which had begun to fail for
about two months. On examination it was found that it was
greatly impaired, for with the right eye he could only read No. 20
of Jager's test types, and with the left No. 19. A strong convex
lens (No. 5), enabled him to read No. 6 indistinctly with the right
eye, and No. 4 with the left. The field of vision was relatively
good in each eye. The refracting media were transparent. The
ophthalmoscope revealed the existence of well-marked nephritic
retinitis. In the right eye, the optic disk was somewhat opaque
and indistinct, and its outline irregular and ill defined. The
opacity of the disk was due to an inflammatory infiltration, which
extended to some distance (three or four times the diameter of the
disk) into the retina ; the latter being here also studded with
numerous irregular white patches and dots, more especially towards
the region of the yellow spot. At the latter point were seen the
peculiar brightly-shining stellate spots, which are so often observed
in the retinitis of Bright's disease. The retinal veins were dilated
and tortuous, but not to a very considerable extent, whereas the
arteries were markedly attenuated. Numerous small striated blood
effusions were strewn about the retina and optic disk. The con-
dition of the left eye was very similar in appearance, excepting that
the peculiar white stellate dots in the region of the yellow spot
were absent, and the extravasations of blood were not numerous.

Note by Dr. Johnson. ' This patient had general dropsy ; the
urine contained a large amount of albumen and numerous oily
casts and cells. I have no doubt that the case was one of large
white fat kidney, but the man left the hospital shortly before his
death, and no p. m. was made.'

Communicated to the author by Dr. Johnson.

110. Albuminuria, retinitis, autopsy.
(Under the care of DR. KUSSELL, of Birmingham.)

' A man, set, 29, first came under notice in January 1867, when
his symptoms were of six months' duration. They were not per-
manently relieved till the end of the year, and again manifested

CASES 109111. 357

themselves in October 1868, after a period of fair health. He was
again admitted in January 1869, and died on June 2. He had
epistaxis at an early date in his disease, and again the day after his
second admission in January 1869. He first observed his sight
to be impaired at the end of 1868. His work, being of a very
delicate character, afforded him a fair test. He found that the
point of the pens on which he was operating looked twisted. It
however appeared that faulty accommodation was concerned in the
defect, as his surgeon, Mr. Figgins, always found his pupils much
dilated, and was able to improve his patient's vision by employing
the Calabar bean. The same condition of pupil was apparent at
his admission, with very defective sight.

O. S. 'Examination, January 2ist, 1869. The outline of the disk
was indistinct ; the vessels diminished in number ; the veins rather
full. There were many small patches of extravasated blood in the
superficial and deep layers of the retina. Shining white spots,
irregular in size and shape, were scattered over the retina, and
there were also patches of degeneration.

' Examination, May 2oth. There was haemorrhage beneath the
conjunctiva of the right eye, covering half the globe. The optic
nerve was whiter than natural. The arteries were small; the
veins full. The white glistening specks were especially abundant
around the yellow spot.

' Autopsy. His kidneys presented a rather early stage of the
granular fatty degeneration of Johnson, presenting single coils of
tubes filled with oil, and hypertrophy of the small arteries.'

Dr. Russell adds in a private letter to me :

f Birmingham, January 22, 1870.

' DEAR DR. ALLBUTT, I was unfortunately prevented from being
present at the post-mortem, but received the following particulars :
" Kidneys somewhat larger and heavier than natural ; capsule peels
off easily, surface smooth, pale fawn coloured. Heart left ven-
tricle thick, pale fawn coloured ; cavities of both ventricles dilated."
I am sorry that they neglected to weigh the organs.'

111. Granular kidneys, hypertrophy of left ventricle, arterial

degeneration and dilatation, retinitis.

Mrs. A., set. 46, a patient of Mr. S. Hey. Noticed one day,
after some extra-exertion, that she had a pulsating swelling in the

358 APPENDIX.

neck. I was requested to see her in consultation with Mr. Hey.
She had a very sallow aspect, was ill-nourished, skin harsh and
wrinkled, urine abundant, of a low specific gravity, and containing
small quantities of albumen. A pulsating tumour was present
in the right neck above the collar-bone, and its percussion dulness
extended downwards over the upper third of the sternum and for a
finger's breadth to the right of the sternum. The swelling was of
very variable size, and greatly receded when perfect rest was ob-
served. It was always present, however, to the extent of a finger's
breadth above the right collar-bone. The swelling could also be felt
to pulsate above and behind the sternum on pressing the finger into
the notch. There was a murmur with the first movement of the
heart, and this was heard all over the tumour. Two years' observa-
tion of this patient convinced Mr. Hey and myself that we had to
do with a diseased arterial system generally, and in particular with
a dilated aorta and innominate artery. We did not examine the
retinae until one morning we were both summoned to her, because
she had become suddenly blind of the right eye. On examination
with the mirror we found an advanced state of nephritic retinitis.
One disk was surrounded by a rampart of fatty accumulation ; in
the other eye there were disseminate patches, and a constellation
round the yellow spot.

Mr. Teale also saw the patient on several occasions. She suffered
from slight cerebral symptoms for some months after this, and
ultimately died in about three years from the time of our first
visits, worn out by general disease. There were no distinct symptoms
of encephalic haemorrhage, but rather of embolism.

112. JBright's retinitis, granular kidney, no hypertrophy of heart.

Thomas W was admitted under the author's care in the Leeds

Infirmary on the 5th of August, 1869. He complained of general
debility and ill health. His complexion was sallow, he was wasted,
and his skin was harsh. His urine was of s. g. 1010, and it
contained a decided though small quantity of albumen. The valves
of the heart were competent, its dulness of normal extent, and its
cavities of normal size.

O. S. The eyes presented a marked example of albuminuric retinitis.
Both retinae were in advanced disease ; haemorrhages numerous ;
fatty patches large and confluent. Vision much deteriorated.

The patient ceased to attend after a few weeks.

CASES 112115. 359

113. fietinitis, waxy kidney.

1 Archibald M , set. 40, under the care of Dr. Grainger Stewart,

was suffering under anaemia, with the symptoms of waxy disease
of the viscera of the abdomen. His vision was impaired.

1 0. S. Ketinitis was observed by Dr. Argyll Kobertson in both
eyes, with commencing degenerative changes, and several points of
blood extravasation.

'He sank and died comatose from anaemia about three weeks
later. On post-mortem examination, waxy degeneration of kid-
neys, liver, and spleen was found.'

From Dr. Grainger Stewart's work on ' Bright's Disease/

114. Syphilis, headache, neuro-retinitis.

S. M., set. 28, was admitted under the author on Dec. 17, 1869.
Contracted syphilis six years ago, the chancres, of which there were
two, being hard and difficult of cure. His habits had been any
thing but temperate. Four months ago, after a drinking bout,
a severe headache commenced in the left temple, ' striking into the
left eye.' The sight of the eye gradually failed, and in a week
was gone ; the other soon followed it. On admission he had intense
paroxysmal headache, and could scarcely distinguish light. As I
had scarcely entered into the case on my first visit, I ordered a
blister over the supra-orbital branch, which was successively painful,
with morphia and aconite dressings. He had obtained no relief in
three days, when I saw him again, and found a typical example of
neuro-retinitis in both eyes. Under full specific treatment he lost
his headache, and regained his sight so far as to read the news-
paper. Much of the exudation about the disks was reabsorbed
before we lost sight of him.

See many cases of syphilis with neuro-retinitis in a paper by the
author in the fourth vol. of * S. Geo. Hosp. Reports.'

115. Syphilitic retinitis.

Feb. n, 1869.

These two cases the author owes to the kindness of his friend
Mr. Oglesby, of Leeds.

E. C., set. 29, single woman, complains of failing sight. Has
been ailing for some time from rheumatic pains, chiefly in the head,
which were at one time so severe as to produce convulsive attacks
of a serious nature. She shuns a bright light, and shrinks from an

360 APPENDIX.

ophthalmoscopic examination, as it is extremely painful to her. The
outline of the disks is obscure, and the retina in their immediate
vicinity is very hazy and grey. The retinal veins are enlarged and
tortuous, but the calibre of the arteries is normal. On close ex-
amination, minute specks of pigment are found to be scattered over
the periphery of the retinae, not unlike the deposition of pigment
which occurs in cases of night blindness. She has been under treat-
ment for constitutional symptoms, and her general health is much
improved, but vision steadily diminishes. Treatment proved un-
availing, and when last seen she complained that each day her sight
grew worse.

Also 116.

July, 1870.

A young man labouring under the hereditary form of syphilis,
and having the characteristic facial expression, applies for relief on
account of severe aching pain in the globe of the right eye and
supra-orbital region. He also stated that vision had for some
weeks been very imperfect. There was slight tension, but no ap-
pearance of inflammation of cornea or iris. The ophthalmoscope
disclosed an interesting condition of retina. Two patches of lymph
of considerable size rested on the retina, one immediately above, the
other immediately below the optic disk. Both were in the course
of large vessels which crossed the patches, but were never so entirely
lost disappearing at one edge, re-appearing at the other as we
find in congenital nerve patch. The retinal vessels were extremely
numerous and much enlarged, though not tortuous. The other
parts of the retina appeared healthy. Under appropriate treat-
ment cod liver oil and tonics the lymph patches slowly dis-
appeared, leaving behind them functional impairment of retina.

117. Lead poisoning, optic neuritis.

i A young girl presented marked symptoms of lead poisoning ; had
suffered of late from several sudden losses of consciousness. She
was able to distinguish lamplight at two yards' distance.

' 0. S. Pupil dilated, field of vision much contracted. Media of eye
transparent. Disks swollen, presenting a reddish grey and opake
colouring ; retina around the disk presents like opacity. Eetinal
veins large, tortuous, and dark coloured ; arteries small and pale.'

E. Meyer. One of two cases published in the ' Union Medicale,'
No. 76, 1868.

GASES 116120. 361

118. Lead poisoning, atnblyopia.

'A house painter, set. 35 years, was seized quite suddenly with
dimness of vision four days after the commencement of an attack
of colic. The amblyopia increased so rapidly that on the seventh
day from its first appearance he had but the dimmest perception of
mere light.

' O. S. There was a dull grey colouring of both disks, with a
decided loss of transparency.

'The powers of vision returned completely under appropriate
treatment.'

Hirschler, 'Wien. Med. Wochenschr.' 1866, Nos. 7 and 8, quoted
in several journals.

119. Lead poisoning, optic neuritis.
(Under the care of Mr. HUTCHINSON.)

Mary W., set. 19, admitted at Moorfields July 13, 1867. Blind.
Pupils large and fixed. Worker in lead mill two years. Four
months ago colic, and slightly dropped wrists. Recovery. Fourteen
weeks ago vomiting, pain in head, dim vision for five weeks, when
she became suddenly blind. She had some numbness in the tips
of the fingers.

0. S. ' In both disks were the usual conditions of optic neuritis,
being covered with lymph. There were also numerous apoplexies
near them.'

Condensed from 'Royal Lond. Oph. Hosp. Reports,' vol. vi. p. 55.

120. Lead poisoning , dim vision, atrophy of disks.

1. T., set. 66, painter, admitted under the author, May 22, 1868.
Always healthy, except bad attack of painter's colic, nineteen years
ago. Eight weeks ago seized with confusion of head on right side,
' as if a brush had been drawn down that side and left him dizzy.'
Had a second attack in a few hours, when he fell. He scarcely
lost consciousness but lost speech. He quite understood all ques-
tions, but was unable to reply. He was also palsied on the left side,
of motion only. In fourteen days he began to be able to put
sentences together. On admission arm chiefly palsied, also left
face and tongue. Speech unimpaired. So also hearing and smell
and common sensation. Blue line well marked. Improved under
appropriate treatment.

O. S. Movements of eyeball normal. Pupils normal or a little

362 APPENDIX.

small. Vision for reading dim and useless. Cannot read small
print (small pica). Reads large print. No examination of field of
vision noted, nor were test types used.

Both retinas normal, vessels rather fine, especially arteries ; disks
atrophied to the second degree.

121. Mercurial poisoning, optic neuritis.

W. W., strong, stout man. Calomel manufacturer. Admitted
into Moorfields April 2, 1867. Dim sight five weeks; blindness
three weeks. Had been ill four months with pains in limbs,
tremors, and much headache. No loss of flesh or appetite j weak
and staggering gait.

O. S. Pupils dilated, motionless ; media clear ; optic disk pro-
minent ; vessels protruded and interrupted ; edge of disk un-
defined.

April 8. Delirium ; headache.

May i. Atrophy of disks ; still blind.

There is no more evidence given of the mercurialism. T. C. A.

Case condensed from ' Royal Lond. Oph. Hosp. Reports/ vol. vi.
P- 54-

122. Tobacco amaurosis.
May, 1868.

These two cases the author owes to the kindness of his friend
Mr. Oglesby, of Leeds.

Frank G., set. 50, shoe manufacturer, complains of failing sight.
His previous history is good. He has enjoyed good health. He
has never suffered from syphilis or other constitutional disease. For
some time past he has been mentally depressed, owing to the death
of his wife. He suffers from palsy of the hands. He is a great
smoker, the average quantity of tobacco he consumes per week
being twelve ounces. Rather more than two years ago his vision
became imperfect, and has continued to fail somewhat rapidly up to
the present time. The ophthalmoscope disclosed commencing atro-
phy of disks, which rapidly increased, and ultimately resulted in
blindness.

Also 123.

Dec. 1869.

J. M., set. 40, circus-manager, complains of inability to follow his
business on account of failing sight. He is irritable and nervous.

GASES 121123. 363

Has hitherto enjoyed excellent health. He has been in the habit
of smoking the enormous number of twenty-seven cigars per day
for a length of time, but was not aware that any injury to health
was likely to follow such a habit. Vision is extremely imperfect.
The disks are brilliantly white. There is slight palsy of the hands,
and great nervousness. I have been unable to watch the case
further.

THE tables which conclude the Appendix are the reports of a
long and arduous series of observations made upon the insane,
chiefly among those in the "West Riding Asylum, under the care of
Dr. Crichton Browne, and in the North and East Riding Asylum,
then under the care -of Dr. Christie. The diagnosis in each case
is given by Dr. Browne or by Dr. Christie. These tables were
first published in the fifty-first volume of the ' Medico-Chirurgical
Transactions,' in the hope that the indications of the ophthalmo-
scope may offer some test by which the alienist physician may sift
the unwieldy mass of diseases with which he has to deal, and may
approach a more certain knowledge of the various pathological con-
ditions of his patients. Individually the cases are only valuable
when verified by autopsies, but taken collectively they seem worthy
of republication.

364 OPTIC NERVES AND RETINA

INSANITY WITH EPILEPSY.

Of insanity depending upon epilepsy I have noted forty-three
cases. It may surprise some of my readers to be told that when
compared with general paralysis, mania, and dementia, the pro-
portion of epileptic cases which present symptomatic changes in
the eye is small.

I note disease of the optic nerve or retina in fifteen cases out of
the forty-three. I mark nine as doubtful ; the remaining nineteen
showed no diseased change.

I have said, however (vide chap. v. p. 82), that epilepsy alone
(not dependent upon organic disease) is not usually accompanied
by disease of the optic nerve, but that a change in the vessels of the
retina may be seen at times in epilepsy, and some of the following
cases seem to bear this out. On an examination of the table it
will be seen that organic disease was known by unilateral symp-
toms, or otherwise, to exist in most of the cases in which the optic
nerves are noted as diseased.

AS SEEN IN THE INSANE.

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OPTIC NERVES AND RETINA

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AS SEEN IN THE INSANE. 371

MANIA.

Of mania I have noted fifty-one cases. Of these, the state of
the nerves was, in twenty-five cases, symptomatic of intracranial
disease j in thirteen cases it was of doubtful meaning ; and in
thirteen cases I found either no changes at all or only local
changes, such as glaucoma, myopia, &c. I think the reader will
be surprised to hear of symptomatic change being found and
suspected in so large a number of cases. It was far more than
I looked for. But it will be remembered, on the other hand,
that the patients submitted to me were always well-marked cases
of disease, and in the larger proportion of them organic disease
was suspected on grounds independent of my observations. From
my list of mania cases I propose the following points for future
investigation :

(1) That symptomatic changes in the eye are to be found in
a large proportion of cases of mania.

(2) That if cases known to be functional only, or incorrectly
named (such as erotomania, transient mania, hysteria, &c.) be
omitted, the proportion of cases presenting permanent change
in or near the optic disks is still larger.

(3) That both in mania depending upon organic causes and
in functional mania the back of the eye, if observed within a
few days after a paroxysm, presents a vascular suffusion or pink-
ness, a pinkness so great after severe paroxysms as to obscure
the disk. No exudation is seen in these cases, unless there exist
some permanent mischief.

(4) That during the paroxysm, on the contrary, the disk is
anaemic, perhaps from spasm of the vessels.

(5) That the permanent changes in the disk are due either
to stasis from obstruction to the intracranial circulation, with
consecutive atrophy ; or to ramollissement ending in simple white
atrophy ; or they may present changes of a mixed character.

I may make a few further remarks upon my propositions
concerning the hypersemia or blush of the disk and fundus in
mania. I found this so frequently in maniacs who had recently
passed through a paroxysm, that I began to think I could detect
cases of mania by this appearance only. However, I carefully

B b 2

372 OPTIC NERVES AND RETINAE

avoided any theorising during my investigations, lest I should
unwittingly vitiate my observing powers. On reading my lists
over, however, it occurred to me that this suffusion, which I
also saw sometimes upon the conjunctiva, might be due to a
paralysis of the vaso-motor nerves.

I instantly turned to the notes of a case which I had by good
luck been able to observe during a paroxysm, a piece of rare
good fortune (vide case 31).

I had there noted an anaemic retina, and a whitish state of
the disk which I put down to commencing atrophy, though with
some doubt. May there be in the eye, and so in the brain, a
spasm of the arteries an epilepsy of the mental functions
followed by a paralytic dilatation of longer or shorter duration ?
Of course my one case can be nothing more than a suggestion
of such a mode of action. The appearances of excessive vascu-
larity seemed to last, on an average, from five to eight days. I
watched its fading in several cases.

AS SEEN IN THE INSANE.

373

374

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380 OPTIC NERVES AND RETINAE

DEMENTIA.

The next schedule contains thirty-eight cases of dementia not
connected with epilepsy. Most of them, however, were due to
organic disease in the brain, and were picked out for their
severity.

Of these I found disease in the optic nerve or retina in twenty-
three cases ; I found six in a doubtful condition, and nine were
healthy. It will be seen that in simple acute dementia (uncom-
plicated with organic disease), however profound, no changes in
the optic nerve are recorded.

I will only note further, that in dementia, where atrophic
changes were seen by the ophthalmoscope, I both made inquiries
concerning the sight, and, in some cases, tested it. I confirmed
my former belief, that statements concerning visual power, whether
made by patients, or by their friends, are of no value (vide De-
mentia, e. g. No. 29) ; and, moreover, that failure of sight, as
tested by types, is wholly an oculist's symptom, and bears little
proportion to the amount of atrophic or other disease that may
be seen in the nerve. Mapping of the field of vision is a most
important physician's symptom, but with lunatics this would
have been out of the question.

AS SEEN IN THE INSANE.

381

382

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AS SEEN IN THE INSANE. 387

MELANCHOLIA AND MONOMANIA

In melancholia, and monomania, which I have tabled together
for convenience, the relation of events is changed. As a large
proportion of these affections are functional only, so I find, on
analysing my list, that of seventeen cases, the optic nerve and retina
were healthy in ten, doubtful in four, diseased in three cases. Of
ihefour marked as doubtful, the case of John Booth (No. 1 of the
table), which is noted as possibly a case of commencing atrophy
of disk, has since shown symptoms of locomotor ataxy, as Dr. Browne
tells me. This event accounts for my suspicion of commencing
atrophy. I find in the three diseased cases that Dr. Browne notes
' atheroma of vessels' in one ; in another 'probable organic disease' ;
in the third, ' chronic disorganization of the brain.'

I very frequently noted the presence of anaemia of the retina in
melancholia.

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388

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390 OPTIC NERVES AND RETINA

IDIOCY.

The next table is one of idiocy.

I examined some idiots because I had formed a suspicion from
the few cases which had occurred in my own practice, that atrophy
of the optic nerves was not uncommon in idiocy (vide chap. v.
p. 91). It will be seen that of twelve cases I note very decided
atrophy of the disks in five, and advancing disease in one, while
two may be called doubtful. Whether this be due to encephalic
inflammations in childhood, or to whatever causes it may be, I
leave to future observers to say.

AS SEEN IN THE INSANE.

391

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392

OPTIC NERVES AND RETINA

AS SEEN IN THE INSANE. 393

GENERAL PARALYSIS.

The next schedule contains fifty-three cases of general paralysis,
in five of which I find no change in the optic nerve and retina.

Of the remaining forty-eight, I find atrophy of the optic disks in
its various stages in forty-one cases, and seven cases must be marked
as doubtful. In all doubtful cases I made two or three examina-
tions at intervals of a few weeks.

I note the following points :

(1) That atrophy of the optic nerves takes place in almost every
case of general paralysis, and, I may add, of the olfactory nerves
also.

(2) That it does not travel down from the optic centres and
along the tracts, but attacks the optic nerves as an independent
tract of sclerosis.

(3) It often becomes apparent as a hypersemia of the nerve with
slight exudation, but without much stasis as a ' red softening,' in
fact. It then whitens, generally from the outer edge inwards, the
nerve becoming white and staring, and its edge sharply defined.
(Sometimes it takes a slate colour. Vide Liebreich, pi. xi., figs. 6,

12.)

From Case 38 it appears that the smaller vessels become fine
and very tortuous before they vanish. If there has been decided
exudation, the edges are, for a time, uneven, but the 'punched-out'
look always establishes itself in the end.

(4) The atrophy of the nerve seems to bear no fixed proportion
to the ataxy of the orbital muscles seen in general paralysis. This
ataxy is probably dependent upon the same causes as the ataxy of
the articulating and other muscles.

(5) The nerve changes are generally proportionate to the well-
known contraction and dilatation of the pupils. These contract in
the early or hyperaemic stage, and dilate as white atrophy succeeds.

(6) As atrophy of the optic nerves can seldom be surely ascer-
tained in the incipient stages of general paralysis, its diagnostic
significance, therefore, is not great. Its value lies rather in its
important pathological significance.

394 OPTIC NERVES AND RETINA

Appendix to Cases of General Paralysis.

Dr. Browne has been kind enough to forward to me a report of
such autopsies as have taken place upon any of the following cases,
viz. upon Nos. 3, 4, 10, 12, 14, 18, 19, 26, 33, 47. In all, the
membranes were found thickened and the convolutions wasted and
water-logged. In all but two atheromatous disease of the arteries
is noted.

In No. 3. The corpora striata, thalami, and corpora quadri-
gemina were * flattened, as if wasted.'

In No. 4. ' All the cerebral nerves much wasted ; the optic
nerves, commissure, and tracts, especially, atrophied.'

In No. 14. 'The optic thalami flattened, as if wasted.'

In. No. 1 8. 'Corpora quadrigemina flattened, wrinkled, and
softened \ cerebral nerves also softened.'

In No. 26. In addition to the usual changes in the membranes
and convolutions, the optic nerves were degenerated. Dr. Browne
says, ' the nerves appeared quite plump and round, and I should
have reported them as healthy but for their white glistening
appearance. On examination they were quite without consistence,
and were chiefly made up of connective tissue and watery fluid.'

In No. 47. ' Optic nerves, commissure, and tracts, white, flat-
tened, and wasted.'

AS SEEN IN THE INSANE.

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OPTIC NERVES AND RETINA

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Edward Thornton,
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400

OPTIC NERVES AND RETINJS

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OPTIC NERVES AND RETINA

A3 SEEN IN THE INXAXE. 405

The main inferences from these schedules, which are too long to
examine in detail, are that in old or severe organic disease of the
brain and its membranes, whether degenerative, heemorrhagic,
meningitic, or due to tumours, obvious changes in the eye are to
be seen in a very large proportion.

That in so-called functional diseases, however profound, such
changes are to be found only in a very small proportion.

That atrophy of the disk is a common if not a constant symptom
of general paralysis, a fact of the highest pathological importance.

That in mania and epilepsy, but especially in the former, the
variations of vascular tension in the retina and disk may have
great interest for the observer.

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